2025 ICD-10-CM code S02.831A
Fracture of medial orbital wall, right side, initial encounter for closed fracture.
Medical necessity for services related to S02.831A is established by the presence of a fracture confirmed by imaging and the need for intervention to restore function and prevent complications.
Diagnosis and treatment of the fracture are typically managed by ophthalmologists, oculoplastic surgeons, or other specialists skilled in facial trauma. Their responsibilities include assessing the extent of the injury, determining the need for surgical intervention, and providing appropriate follow-up care.
- S00-T88 Injury, poisoning and certain other consequences of external causes
- S02 Fracture of skull and facial bonesS02.8 Fracture of other facial bonesS02.83 Fracture of medial wall of orbitS02.831 Fracture of medial orbital wall, right sideS02.831A Fracture of medial orbital wall, right side, initial encounter for closed fracture
In simple words: A break in the inner bone of your right eye socket that hasn't broken the skin, diagnosed during your first visit for it.
Fracture of medial orbital wall, right side, initial encounter for closed fracture. This code specifies a break in the bone of the medial wall of the right eye's orbit, occurring during the initial encounter for a closed fracture. A closed fracture indicates that the broken bone has not pierced the skin.
Example 1: A patient presents to the emergency room after being struck on the right side of the face by a baseball. Imaging reveals a closed fracture of the medial orbital wall, right side. This is the patient's first encounter for this injury, so S02.831A is used., During a fight, a person receives a blunt force injury to the right eye. Subsequent examination reveals a fracture of the medial orbital wall. As this is the initial encounter for the injury, S02.831A is the appropriate code., A patient falls and hits their head, specifically the area around the right eye, and the initial examination confirms a right medial orbital wall fracture, without skin breakage. This being the initial presentation of the injury, S02.831A is the correct code.
Detailed clinical documentation should include the circumstances of the injury, physical examination findings (e.g., periorbital edema, ecchymosis, diplopia, enophthalmos), and results of imaging studies (e.g., CT scan, X-ray) confirming the fracture location and type.
** It's essential to differentiate S02.831A from other related codes, including those for open fractures (S02.831B) or fractures involving different parts of the orbit.
- Specialties:Ophthalmology, Oculoplastic Surgery, Emergency Medicine, Maxillofacial Surgery
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center