2025 ICD-10-CM code S02.3

Fracture of orbital floor (inferior wall of eye socket).

Use secondary code(s) from Chapter 20 (External causes of morbidity) to indicate the cause of injury.Additional codes should be used for any associated intracranial injury (S06.-) and any retained foreign body, if applicable (Z18.-).

Use 7th character to indicate the type of encounter and healing status.

Medical necessity is established by the clinical findings supporting the diagnosis of an orbital floor fracture, such as imaging studies, physical exam findings, and patient symptoms.

Patients may present with diminished visual acuity, double vision, drooping eyelids, restricted vertical eye movements, subconjunctival hemorrhage, loss of sensation over the upper cheek area, periorbital bruising, or rupture of the eyeball itself. Diagnosis is based on patient history, physical examination, and CT scan. Treatment options include medical management with analgesics, antibiotics, and corticosteroids for patients without eyeball depression, a fracture of less than 50% of the orbital floor, or those without vision impairment; surgical repair of the fracture, possible surgical placement of an orbital implant or prosthetic eye.

In simple words: A blowout fracture is a break in the floor of the eye socket.

Fracture of orbital floor. Fracture of inferior orbital wall. Excludes1: orbit NOS (S02.85). Excludes2: lateral orbital wall (S02.84-), medial orbital wall (S02.83-), orbital roof (S02.1-)

Example 1: A patient presents to the emergency room following a fistfight with periorbital swelling and ecchymosis, diplopia, and limited upward gaze. A CT scan reveals a fracture of the right orbital floor. Code: S02.31XA, A patient is seen in follow-up after surgical repair of a left orbital floor fracture. The fracture is healing normally. Code: S02.32XD , A child falls from a tree and lands on their face, resulting in bilateral orbital floor fractures. Code: S02.33XA

Documentation should include the type of fracture (open or closed), location (right, left, or bilateral), and the status of healing (initial encounter, subsequent encounter with routine healing, delayed healing, nonunion, or sequela). Imaging reports (CT scan) should be included.

  • Specialties:Ophthalmology, Plastic Surgery, Emergency Medicine, Maxillofacial Surgery
  • Place of Service:Emergency Room - Hospital, Inpatient Hospital, On Campus-Outpatient Hospital, Physician's Office
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