2021 ICD-10-CM Code S04.042S

Injury of visual cortex, left side, sequela

Version 2021

Valid for Submission

S04.042S is a billable diagnosis code used to specify a medical diagnosis of injury of visual cortex, left side, sequela. The code S04.042S is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S04.042S is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of a condition like injury of visual cortex left side. According to ICD-10-CM Guidelines a "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.

ICD-10:S04.042S
Short Description:Injury of visual cortex, left side, sequela
Long Description:Injury of visual cortex, left side, sequela

Code Classification

Coding Guidelines

The appropriate 7th character is to be added to each code from block Injury of cranial nerve (S04). Use the following options for the aplicable episode of care:

Present on Admission (POA)

S04.042S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert S04.042S to ICD-9 Code

The General Equivalency Mapping (GEM) crosswalk indicates an approximate mapping between the ICD-10 code S04.042S its ICD-9 equivalent. The approximate mapping means there is not an exact match between the ICD-10 code and the ICD-9 code and the mapped code is not a precise representation of the original code.

Information for Patients


Traumatic Brain Injury

Also called: Acquired brain injury, TBI

Traumatic brain injury (TBI) happens when a bump, blow, jolt, or other head injury causes damage to the brain. Every year, millions of people in the U.S. suffer brain injuries. More than half are bad enough that people must go to the hospital. The worst injuries can lead to permanent brain damage or death. Half of all TBIs are from motor vehicle accidents. Military personnel in combat zones are also at risk.

Symptoms of a TBI may not appear until days or weeks following the injury. A concussion is the mildest type. It can cause a headache or neck pain, nausea, ringing in the ears, dizziness, and tiredness. People with a moderate or severe TBI may have those, plus other symptoms:

Health care professionals use a neurological exam and imaging tests to assess TBI. Serious traumatic brain injuries need emergency treatment. Treatment and outcome depend on how severe the injury is. TBI can cause a wide range of changes affecting thinking, sensation, language, or emotions. TBI can be associated with post-traumatic stress disorder. People with severe injuries usually need rehabilitation.

NIH: National Institute of Neurological Disorders and Stroke


[Learn More in MedlinePlus]

Vision Impairment and Blindness

Also called: Low vision

If you have low vision, eyeglasses, contact lenses, medicine, or surgery may not help. Activities like reading, shopping, cooking, writing, and watching TV may be hard to do. The leading causes of low vision and blindness in the United States are age-related eye diseases: macular degeneration, cataract and glaucoma. Other eye disorders, eye injuries, and birth defects can also cause vision loss.

Whatever the cause, lost vision cannot be restored. It can, however, be managed. A loss of vision means that you may have to reorganize your life and learn new ways of doing things. If you have some vision, visual aids such as special glasses and large print books can make life easier. There are also devices to help those with no vision, like text-reading software and braille books.

The sooner vision loss or eye disease is found and treated, the greater your chances of keeping your remaining vision. You should have regular comprehensive eye exams by an eye care professional.

NIH: National Eye Institute


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Code History

  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)