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2025 ICD-10-CM code S45.999S

Sequela of other specified injury of unspecified blood vessel at the shoulder and upper arm level, unspecified arm.

Use a secondary code from Chapter 20, External causes of morbidity (V01-Y99) to indicate the cause of the initial injury. If a foreign body is retained at the injury site, also code Z18.-. Do not use this code for birth trauma (P10-P15) or obstetric trauma (O70-O71).

Medical necessity for the use of this code is established by the presence of signs, symptoms, or conditions directly attributable to the late effects of the original injury to the blood vessel. The documentation should link the current complaint to the previous injury.

In simple words: This code refers to the long-term effects of a previous injury to a blood vessel in your shoulder or upper arm area. It's used when you're seeing a doctor for problems related to the old injury, not the original injury itself.

This code describes the long-term consequences or residual effects of a specified injury to an unspecified blood vessel at the shoulder and upper arm level, unspecified arm. This code is used for encounters subsequent to the initial injury.

Example 1: A patient presents with chronic pain and limited range of motion in their left shoulder, a year after a car accident that caused an unspecified injury to a blood vessel in their upper arm., A patient experiences persistent numbness and tingling in their right hand several months after a fall that injured a blood vessel near their shoulder. They are now being evaluated for potential nerve damage., A patient develops a persistent swelling in their upper arm, months after an injury that damaged an unspecified blood vessel. They are being seen for ongoing monitoring and management of this condition.

The documentation should clearly indicate that the current encounter is related to the sequela (late effect) of the previous injury to the blood vessel at the shoulder and upper arm level. The original injury should be documented, along with the specific residual effects the patient is experiencing. Details of the affected arm (right, left, or unspecified) should also be documented, although in this specific code, the arm is unspecified.

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