2025 ICD-10-CM code S02.12
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Fracture of skull and facial bones S00-T88 Feed
Fracture of orbital roof.
Modifiers may be applicable to indicate laterality (right or left) and episode of care (initial encounter, subsequent encounter, or sequela).
Medical necessity is established by the presence of a fracture confirmed through appropriate imaging studies and associated signs and symptoms, such as pain, swelling, visual disturbances, or neurological deficits.
Diagnosis and treatment are typically managed by ophthalmologists, oculoplastic surgeons, or other specialists dealing with facial trauma.
In simple words: A break in the bone forming the roof of the eye socket.
Fracture of orbital roof.
Example 1: A patient presents to the emergency room after being struck in the face with a baseball. Imaging reveals a fracture of the orbital roof., During a motor vehicle accident, a patient sustains blunt force trauma to the head, resulting in a fracture of the orbital roof, among other injuries., A patient falls from a ladder and lands on their head, leading to a fracture of the orbital roof and requiring surgical intervention.
Documentation should include details of the injury mechanism, physical examination findings, imaging results (e.g., CT scan, X-ray), and associated injuries.Neurological assessment findings should also be documented.
** Excludes birth trauma (P10-P15) and obstetric trauma (O70-O71).
- Payment Status: Active
- Specialties:Ophthalmology, Oculoplastic Surgery, Emergency Medicine, Trauma Surgery, Neurosurgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Physician's Office,Ambulatory Surgical Center