S04.041 ICD-10-CM Code: Injury of visual cortex, right side

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for S04.041 in the official ICD-10-CM tabular list, quoted as published.

Source: CMS/CDC — ICD-10-CM Tabular ListRelease: FY2026Effective: October 1, 2025

Notes without a marker are published on S04.041 itself; “inherited from” names the category or block whose note applies here.

7th Character Guide

"The appropriate 7th character is to be added to each code from category S04"

• A — initial encounter
• D — subsequent encounter
• S — sequela

How the encounter character is assigned. “Initial encounter” means the patient is receiving active treatment for the condition — it is not limited to the first visit, and a different or new provider giving active treatment still assigns it. “Subsequent encounter” covers care during the healing or recovery phase after active treatment. “Sequela” is for complications or conditions that arise as a direct result of the original condition.

ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19.a (paraphrased by MedCoder).

Variant codes in this family

S04.041A, S04.041D, S04.041S

Character meanings are CMS's official 7th-character extensions for this family, as carried in each variant code's official description; variant codes are registry rows. The explanation of how the encounter character is assigned is MedCoder editorial, distinct from the official content above it.

Coder workflow for S04.041

MedCoder structured workflow — derived from this code’s own official record

Before you code S04.041

1. S04.041 is not reportable as written. Select the more specific code beneath it that the documentation supports. Codes are reported to the highest level of specificity the classification provides (Guidelines I.B.2).

   ReviewS04.041A, S04.041D, S04.041S

   See the relationships section · Guide: How to choose an ICD-10-CM code →

2. A 7th character is required in this family. Confirm the documented encounter: initial (active treatment), subsequent (healing or recovery phase), or sequela. S04.041 is not valid without one. “Initial” means active treatment, not the first visit (Guidelines I.C.19.a).

   See the 7th Character Guide · Guide: 7th characters: initial, subsequent, sequela →

3. Laterality is coded in this family. Confirm the side documented — right, left, or bilateral — and select the matching code (this page’s code: right). The unspecified-side code applies only when the record states no side. Laterality is assigned from the documented side; where a bilateral code exists and both sides are documented, it is used instead of two unilateral codes (Guidelines I.B.13).

   ReviewS04.042 · left, S04.049 · unspecified

   Guide: Laterality coding →

4. Confirm the injury type, the anatomical site at the most specific level documented, laterality where the family codes it, and the encounter for the 7th character. Each injury is coded separately unless the classification provides a combination code, and a superficial injury is not coded when a more severe injury of the same site is documented. Injury chapter guidelines (Guidelines I.C.19.b, I.C.19.b.1).

   Guide: 7th characters: initial, subsequent, sequela →

Choose the right path

1. Does the documentation support one of the more specific codes beneath S04.041?
   Yes → Select that code and continue the checks below on its own page.
   No → S04.041 cannot be reported as written; query for the specificity its subcategory needs.

   ReviewS04.041A, S04.041D, S04.041S

2. Is the underlying (etiologic) condition the Code First note names documented?
   Yes → Sequence the underlying condition first, then S04.041.
   No → Continue; do not add an underlying condition the record does not document.

   ReviewS06

3. Is the side documented?
   Yes → Select the code for the documented side (or the bilateral code when both sides are documented and one exists).
   No → Use the unspecified-side code only when the record states no side; a query is the alternative.

   ReviewS04.042 · left, S04.049 · unspecified

4. Is the encounter phase documented — active treatment, healing or recovery, or a sequela?
   Yes → Assign the matching 7th character; the variant codes are in the 7th Character Guide.
   No → The code is invalid without its 7th character — query for the missing element.

Consider S04.041. Then work the Use Additional Code note and review the Code Also note, and confirm the code is valid for the date of service in the Verify section.

Documentation check

The provider’s diagnostic statement

Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).

Anatomical site

At the most specific level the record states; a site the classification separates cannot be assumed from a procedure or a measurement.

Laterality

Right, left or bilateral as documented; unspecified only when the record states no side (Guidelines I.B.13).

Encounter type

Active treatment, healing or recovery phase, or sequela — the basis of the 7th character (Guidelines I.C.19.a).

The underlying (etiologic) condition

Named in the Code First note; sequenced before this code when documented (Guidelines I.A.13).

The conditions the Use Additional Code note names

Reported with this code when documented; a conditional instruction (“if applicable”, “if known”) applies only when the record supports it.

External cause, place and activity

For the external cause codes reported with the injury or poisoning, where documented (Guidelines I.C.20.a).

Official instructions as workflow

• Excludes2 — not part of S04.041(9 notes)

  Coding workflow: The conditions named in this note are not included in S04.041. When the record documents both, both may be reported; the note is a boundary, not a prohibition.

  CompareT16, T17.3, T18.0, T17.2, T15, T63.4

  See the official tabular notes · Guidelines I.A.12.b

• Code First — sequencing check(1 note)

  Coding workflow: Check whether the underlying or etiologic condition the note names is documented. When it is, sequence it before S04.041. Do not add an underlying condition the record does not document.

  ReviewS06

  See the official tabular notes · Guidelines I.A.13

• Use Additional Code — after identifying S04.041(1 note)

  Coding workflow: Check whether the documentation supports the additional code(s) the note names, and report them with S04.041 when it does. Where the instruction is conditional (“if applicable”, “if known”), it applies only when the record documents the condition.

  ReviewH53.4, H54

  See the official tabular notes · Guidelines I.A.13

• Code Also — related condition(4 notes)

  Coding workflow: Review the related condition when both are documented and the instruction applies. A Code Also note does not fix sequencing; the order follows the circumstances of the encounter.

  ReviewS01, S02

  See the official tabular notes · Guidelines I.A.17

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Don’t confuse S04.041 with…

MedCoder analysis — pairs from this code’s official notes, distinctions written by MedCoder

The codes most likely to be picked instead of S04.041 — named in its own official notes, or sharing its laterality or encounter family — with what separates them and which documentation moves the case. Each links to the full comparison.

• S04.049— Specificity relationship (Review)

  Overlapping diagnoses in the same category.

  Overlapping codes in the same category — the documentation decides which is the more specific fit.

  What moves you there: A record that documents no more than “Injury of visual cortex, unspecified side” takes S04.049; specificity in the record moves it back here.

  Full comparison: S04.041 vs S04.049 →

• S04.042— Laterality relationship (Review)

  Same condition; these differ only in which side is documented.

  The same condition on the other side; the documented side decides, and a bilateral code, where one exists, replaces the pair when both sides are documented.

  What moves you there: A documented left side moves the case to S04.042.

  Full comparison: S04.041 vs S04.042 →

• S04.041A— Encounter relationship (Review)

  Same underlying diagnosis, different encounter phase.

  The same diagnosis at a different phase of care; one encounter takes one 7th character.

  What moves you there: Documentation of a initial encounter moves the case to S04.041A.

  Full comparison: S04.041 vs S04.041A →

• S04.041D— Encounter relationship (Review)

  Same underlying diagnosis, different encounter phase.

  The same diagnosis at a different phase of care; one encounter takes one 7th character.

  What moves you there: Documentation of a subsequent encounter moves the case to S04.041D.

  Full comparison: S04.041 vs S04.041D →

• T20— Excludes2 relationship (Informational)

  Distinct conditions — both may be reported.

  A distinct condition — both may be reported when both are documented.

  What moves you there: Documentation of burns and corrosions adds T20; it is not part of this code and both may be reported when both are documented.

  Full comparison: S04.041 vs T20 →

• T32— Excludes2 relationship (Informational)

  Distinct conditions — both may be reported.

  A distinct condition — both may be reported when both are documented.

  What moves you there: Documentation of burns and corrosions adds T32; it is not part of this code and both may be reported when both are documented.

  Full comparison: S04.041 vs T32 →

Relationships are read from this code's own official notes, its laterality siblings and its encounter family; the wording of each distinction is MedCoder editorial, and the documentation named in each “what moves you there” line is the official note phrase or sibling title itself. Source: CMS ICD-10-CM tabular instructional notes; ICD-10-CM Official Guidelines, Section I.A.12.a.

Decision Points

The directives on this code's own record, as a pre-claim checklist.

1. A 7th character applies in this family. Confirm the documented encounter matches the character assigned. See the official 7th-character definitions and this code’s variants
2. Laterality is coded in this family. Confirm the documented side matches the code — the opposite-side siblings are in the relationships section. See the opposite-side sibling codes
3. Sequencing: 1 Code First instruction — the underlying condition is sequenced before this code when present. See the Code First notes
4. 1 Use Additional Code instruction — report the named additional code(s) when the documentation supports them. See the Use Additional Code notes
5. 4 Code Also notes — a second code may apply; the guidelines leave its sequencing to the circumstances of the encounter. See the Code Also notes
6. 9 Excludes2 entries — those conditions are not part of this code and may be reported additionally when documented. See the Excludes2 notes

Checklist rows are derived from this code's own official directives; the wording of each check is MedCoder editorial. The official notes themselves are in the sections each row links to.

Verify Before Coding

• Not billable as written — a more specific code is required: S04.041A, S04.041D, S04.041S.
• Requires a 7th character. "The appropriate 7th character is to be added to each code from category S04" Options: S04.041A, S04.041D, S04.041S

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim in Claim Check.

Relationships & Classification

MedCoder structured relationships — computed from published CMS and AHRQ datasets

Other codes that name S04.041 or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

Referenced by 1 Excludes2 note: S05 — Injury of eye and orbit (via S04.0.-).

These codes’ tabular lists name this diagnosis as distinct — both may be reported when both are documented.

Referenced by 4 Code Also instructions across 2 chapters: G96.00 — Cerebrospinal fluid leak, unspecified (via S04.-), G96.08 — Other cranial cerebrospinal fluid leak (via S04.-), G96.09 — Other spinal cerebrospinal fluid leak (via S04.-), S01 — Open wound of head (via S04.-).

These codes suggest coding this condition alongside when both are present.

Related Codes

Same condition, opposite side

Same category and title, differing only in which side of the body is affected.

S04.042 — Injury of visual cortex, left side (left)Compare S04.041 vs S04.042 →, S04.049 — Injury of visual cortex, unspecified side (unspecified)Compare S04.041 vs S04.049 →

Contextual Map

Every relationship of S04.041 in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Run S04.041 with these 5 related codes in Claim Check

Hierarchy

• S00-T88 — Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) (S00-T88)[Hierarchy]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S00-S09 — Injuries to the head[Hierarchy]— CMS ICD-10-CM tabular structure · icd10cm-fy2026

Referenced by Excludes2 notes

• S05 — Injury of eye and orbit[Excludes2](via S04.0.-): “2nd cranial [optic] nerve injury (S04.0-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Referenced by Code Also instructions

• G96.00 — Cerebrospinal fluid leak, unspecified[Code Also](via S04.-): “head injury (S00-S09)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026
• G96.08 — Other cranial cerebrospinal fluid leak[Code Also](via S04.-): “head injury (S00 - S09)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026
• G96.09 — Other spinal cerebrospinal fluid leak[Code Also](via S04.-): “head injury (S00 - S09)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026
• S01 — Open wound of head[Code Also](via S04.-): “injury of cranial nerve (S04.-)”— CMS ICD-10-CM tabular instructional notes · icd10cm-fy2026

Nearest codes (40)

• S04 — Injury of cranial nerve[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.019D — Injury of optic nerve, unspecified eye, subsequent encounter[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.019S — Injury of optic nerve, unspecified eye, sequela[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.02 — Injury of optic chiasm[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.02XA — Injury of optic chiasm, initial encounter[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.02XD — Injury of optic chiasm, subsequent encounter[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.02XS — Injury of optic chiasm, sequela[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• S04.03 — Injury of optic tract and pathways[Sibling]— CMS ICD-10-CM tabular structure · icd10cm-fy2026
• and 32 more

Change history (3)

• FY2018 — Description revised[Change history]— CMS release files (code change ledger) · icd10cm-fy2018
• and 2 more

Common coding questions

Sources for this page

Codes, titles, notes, index terms and mappings on this page are transcribed from the datasets below. Relationships MedCoder computed and text MedCoder wrote are labelled where they appear.

Code, title, tabular notes and index terms Official source data

CMS/CDC ICD-10-CM FY2026 tabular list, index and tables, effective October 1, 2025 Release, file and checksum · Publisher’s page

Claim edits Official source data

CMS Definitions of Medicare Code Edits — v43.1 (April 2026) Release, file and checksum · Publisher’s page

Change history and date-of-service validity Official source data

CMS ICD-10-CM release addenda, ingested release by release into the change ledger Release, file and checksum · Publisher’s page

Comparisons, relationships and the contextual map MedCoder structured relationship

Computed by MedCoder from the tabular notes and tables above; every derived relationship is marked as derived where it appears

Summary and FAQ answers MedCoder explanation

Written by MedCoder to explain the sources above: drafted with AI assistance, checked by a person against the release files, and labelled as MedCoder text where it appears. Not official text.

Labels on this page: Official source data · MedCoder structured relationship · MedCoder explanation. How to read the labels · All data sources and release dates

Nearest Codes in This Family

Official ICD-10-CM classifications closest to S04.041 in its code family, with their registry titles.

• S04.039 — Injury of optic tract and pathways, unspecified side
• S04.039A — Injury of optic tract and pathways, unspecified side, initial encounter
• S04.039D — Injury of optic tract and pathways, unspecified side, subsequent encounter
• S04.039S — Injury of optic tract and pathways, unspecified side, sequela
• S04.04 — Injury of visual cortex
• S04.041A — Injury of visual cortex, right side, initial encounter
• S04.041D — Injury of visual cortex, right side, subsequent encounter
• S04.041S — Injury of visual cortex, right side, sequela
• S04.042 — Injury of visual cortex, left side
• S04.042A — Injury of visual cortex, left side, initial encounter

View all codes in the S04 family