Injury of axillary nerve, unspecified arm, sequela

This code signifies a long-term or late effect of an injury to the axillary nerve, affecting an unspecified arm. It indicates that the initial acute injury has resolved, but the patient continues to experience residual symptoms or deficits attributable to the nerve damage. This could include persistent weakness, sensory loss, or pain in the shoulder and upper arm.

Use this code when documenting a patient presenting with ongoing neurological deficits directly linked to a past axillary nerve injury, after the initial healing phase. This is appropriate for follow-up visits where the sequelae are being managed, rather than the acute injury itself. It applies when the specific arm (left or right) is not documented or is unknown.

• Ensure the medical record clearly documents the "sequela" nature of the condition, indicating a past injury and current residual effects.
• Always attempt to specify the affected arm (left or right) if documented, as more specific codes exist.
• Do not use this code for acute axillary nerve injuries; instead, use the appropriate acute injury code.