Injury of median nerve at forearm level, unsp arm, sequela

This code signifies a long-term or late effect resulting from a previous injury to the median nerve in the forearm. It indicates that the specific arm affected (left or right) is not documented. Patients may present with persistent sensory deficits, motor weakness, or pain in the distribution of the median nerve.

Apply this code when documenting the sequela of a median nerve injury at the forearm level, and the medical record does not specify which arm was affected. This is appropriate for conditions like chronic carpal tunnel syndrome, persistent paresthesia, or muscle atrophy that are directly attributable to a past median nerve trauma.

• Always attempt to clarify the affected arm (left or right) from the medical record to use a more specific code.
• This code should be used as a secondary diagnosis, following the code for the specific sequela (e.g., G56.01 for carpal tunnel syndrome).
• Ensure the "S" seventh character is used for sequela, indicating a late effect of the injury.