Injury, unspecified, sequela

This code signifies a long-term or late-effect condition resulting from an unspecified injury. It is used when the original injury has healed, but a residual problem or complication persists, and the specific nature of the initial injury is unknown or not documented.

Apply this code when a patient presents with a sequela of an injury, but the original injury type (e.g., fracture, sprain, burn) is not specified in the medical record. This is common in cases where a patient is seen for a chronic issue stemming from an old, poorly documented trauma.

• Always attempt to identify the specific type of sequela and the original injury if possible, as more specific codes exist.
• This code should be a last resort when no other specific sequela or injury code can be assigned.
• Requires an additional code to describe the specific nature of the sequela (e.g., pain, scar, deformity).