Laceration of musc/fasc/tend triceps, unsp arm, sequela

This code signifies a past injury involving a tear or cut to the triceps muscle, its surrounding fascia, or its tendon in an unspecified arm. The "sequela" designation indicates that this code is used to report a residual condition or complication arising from the initial laceration, rather than the acute injury itself.

Apply this code when documenting a long-term effect or consequence of a previous triceps laceration, such as chronic pain, weakness, limited range of motion, or scar tissue formation. This code is appropriate when the specific arm (left or right) is not documented or cannot be determined from the medical record.

• Always ensure the documentation clearly supports that the current encounter is for a residual effect of a past triceps laceration.
• Do not use this code for the initial or acute treatment of a triceps laceration; instead, use the appropriate acute injury code.
• If the laterality of the arm is specified in the documentation, select the more specific code (S46.321S for right arm or S46.322S for left arm).