Laceration of axillary or brachial vein, unsp side, sequela

This code signifies a long-term complication or residual effect stemming from a past laceration of a vein in the armpit or upper arm region. This could include issues like chronic pain, nerve damage, or impaired circulation that persist after the initial injury has healed. The specific side of the body is not documented or is unknown.

Use this code when documenting a patient presenting with ongoing problems directly attributable to a previous laceration of an axillary or brachial vein. This applies when the acute injury has resolved, and the current encounter addresses the lasting consequences. It is appropriate when the medical record does not specify which side was affected.

• Always ensure the medical record clearly links the current condition to a previous axillary or brachial vein laceration.
• Look for documentation of "sequela," "due to old injury," or similar phrasing indicating a chronic, residual state.
• Do not use for acute, active lacerations; those would be coded with the initial encounter or subsequent encounter codes.