Injury of axillary nerve, right arm, sequela

This code signifies a long-term or residual effect from a previous injury to the axillary nerve in the right arm. This could manifest as persistent weakness, numbness, or pain in the deltoid and teres minor muscles, or sensory deficits over the lateral shoulder. The original acute injury has resolved, but its lasting consequences are now being addressed.

Use this code when documenting the treatment or evaluation of a patient experiencing ongoing symptoms directly attributable to a past axillary nerve injury in their right arm. This applies to situations where the initial injury occurred at an earlier date and the current encounter focuses on managing the chronic sequelae. Examples include physical therapy for chronic weakness or follow-up for persistent sensory loss.

• Always ensure documentation clearly links the current symptoms to a previous axillary nerve injury.
• This code is for sequelae; do not use it for acute or initial injury encounters.
• Consider additional codes for specific symptoms (e.g., muscle weakness, paresthesia) if they are being treated or evaluated.