2025 ICD-10-CM code S02.31XA
(Active) Effective Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Fracture of orbital floor, right side, initial encounter for closed fracture.
Medical necessity for using this code is established by the presence of a clinically significant fracture of the right orbital floor requiring medical intervention. The documentation should clearly indicate the nature of the fracture and its impact on the patient's health.
Clinical responsibility for this code would typically fall under ophthalmology or potentially, depending on the nature of the injury and treatment required, maxillofacial surgery, or another surgical specialty.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S02.3 Fracture of orbital floorS02.30 Fracture of orbital floor, unspecified sideS02.30XA Initial encounter for closed fractureS02.30XB Initial encounter for open fractureS02.30XD Subsequent encounter for fracture with routine healingS02.30XG Subsequent encounter for fracture with delayed healingS02.30XK Subsequent encounter for fracture with nonunionS02.30XS SequelaS02.31 Fracture of orbital floor, right sideS02.31XA Initial encounter for closed fractureS02.31XB Initial encounter for open fractureS02.31XD Subsequent encounter for fracture with routine healingS02.31XG Subsequent encounter for fracture with delayed healingS02.31XK Subsequent encounter for fracture with nonunionS02.31XS SequelaS02.32 Fracture of orbital floor, left sideS02.32XA Initial encounter for closed fractureS02.32XB Initial encounter for open fractureS02.32XD Subsequent encounter for fracture with routine healingS02.32XG Subsequent encounter for fracture with delayed healingS02.32XK Subsequent encounter for fracture with nonunionS02.32XS Sequela
In simple words: A closed fracture of the bottom part of the eye socket on the right side.
Fracture of orbital floor, right side, initial encounter for closed fracture.Includes injuries of eye.
Example 1: A patient presents to the emergency room after being struck in the right eye by a baseball. Imaging reveals a closed fracture of the right orbital floor., A patient is involved in a motor vehicle accident and sustains a closed fracture of the right orbital floor. This is diagnosed on CT scan., A patient falls and hits their head, resulting in a closed fracture of the right orbital floor, diagnosed via imaging.
Documentation should include details of the injury mechanism, physical examination findings related to the eye and surrounding structures, imaging reports confirming the fracture, and any associated injuries.
** Excludes1: orbit NOS (S02.85). Excludes2: lateral orbital wall (S02.84-) medial orbital wall (S02.83-) orbital roof (S02.1-). Code also: any associated intracranial injury (S06.-)
- Payment Status: Active
- Specialties:Ophthalmology, Maxillofacial Surgery, Emergency Medicine
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital