Injury of axillary nerve, unspecified arm, initial encounter

This code signifies damage to the axillary nerve, which is responsible for sensation over the deltoid and movement of the shoulder. The injury's specific nature (e.g., transection, contusion) is not documented, and the affected arm is not specified. This code is used for the initial treatment of such an injury.

Apply this code for a patient presenting with new onset symptoms consistent with axillary nerve damage, such as deltoid weakness or numbness over the lateral shoulder, when the specific cause or extent of the nerve injury is unknown. It is appropriate when the medical record does not specify whether the left or right arm is affected.

• Ensure documentation clearly indicates an "initial encounter" for treatment of the injury.
• If the specific arm (left or right) is documented, a more specific code should be used.
• Avoid using this code if the exact nature of the axillary nerve injury (e.g., laceration, compression) is known and documented.