Slip/trip w/o fall due to step into hole or opening, sequela

This code describes an injury or condition that is a residual effect of a prior incident where an individual slipped, tripped, or stumbled without falling, specifically caused by stepping into a hole or opening. The initial event has already occurred, and the patient is now presenting with a long-term consequence directly attributable to that past incident.

Use this code when documenting a chronic pain, functional limitation, or other persistent health problem that developed as a direct result of a past non-fall incident involving stepping into a hole or opening. This applies to follow-up encounters where the sequela, not the acute injury, is the primary focus of care. For example, a patient presenting with chronic ankle instability months after a stumble caused by stepping into a pothole.

• Always use this code as a secondary diagnosis, following the code for the specific sequela (e.g., chronic ankle pain, ligamentous laxity).
• Ensure documentation clearly links the current condition to the past non-fall incident caused by stepping into a hole or opening.
• The "S" in the 7th character indicates sequela; do not use for initial or subsequent encounters for the acute injury.