228 A child is diagnosed with partial physeal arrest as a late effect of a Salter-Harris type II physeal fracture of the distal right tibia caused by falling from his skateboard. M89.166 Partial physeal arrest, right distal tibia S89.121S Salter-Harris Type II physeal fracture of lower end of right tibia V00.131S Fall from skateboard Note: The sequence of codes begins with the nature of the sequela (partial physeal arrest), followed by codes describing the related injury and external cause of injury ending with seventh character S to indicate the first-listed condition is a sequela of this injury. Tip: Be sure to include any placeholders (X) necessary to complete a code to the seventh character (eg, S02.2XXS is used to report sequela of fracture of nasal bones). Example 2 A girl who was hospitalized for viral encephalitis 3 months ago is evaluated for learning difficulties that have presented and persisted since the episode of encephalitis. Assessment is deficit of attention and concentration as a late effect of viral encephalitis with probable attention-deficit/hyperactivity disorder (ADHD). R41.840 Attention and concentration deficit B94.1 Sequelae of viral encephalitis Note: In this example, code B94.1 requires no additional character to identify a sequela of viral encephalitis. Codes in categories B90–B94 are used to report sequelae of infectious and parasitic diseases. An instruction at categories B90–B94 directs to code first the condition resulting from the sequela of the infectious or parasitic disease. (Note: The “probable” or unconfirmed diagnosis of ADHD is not reported.) Similar codes for sequela are provided for other conditions. Examples include E64.0 Sequelae of protein-calorie malnutrition (Does not include retarded development following protein-calorie malnutrition [E45]. Report E45 also when appropriate.) E68 Sequelae of hyperalimentation G09 Sequelae of inflammatory diseases of central nervous system G65.0 Sequelae of Guillain-Barré syndrome G65.1 Sequelae of other inflammatory polyneuropathy G65.2 Sequelae of toxic polyneuropathy I69.31 Cognitive deficits following cerebral infarction Locating Codes For sequela of conditions other than injuries, always start with the term Sequelae in the alphabetic index of ICD-10-CM for reference to the correct code category and follow any further directions for reporting as provided in the tabular list. For injuries, see the type of injury (eg, burn, crushing injury) by site with seventh character S. External cause of injury is also indexed by cause and reported with the appropriate code appended with seventh character S. Appendix B-2 Transitioning to 10: Late Effects or Sequela (continued from page 227)
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