2025 ICD-10-CM code S02.831B
(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 medial orbital wall, right side, initial encounter for open fracture.
Medical necessity is established by the presence of a fracture confirmed by imaging studies and the need for treatment to restore function and prevent further complications.In the case of an open fracture, the medical necessity is heightened due to the increased risk of infection.
The physician is responsible for diagnosing the fracture through physical examination and imaging studies (like CT scans), determining the appropriate treatment (which could range from conservative management to surgery), and providing follow-up care.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)Fracture of skull and facial bones (S02.-) Fracture of other skull and facial bones (S02.8-)Fracture of medial orbital wall (S02.83-) Fracture of medial orbital wall, right side, initial encounter for open fracture (S02.831B)
In simple words: Open fracture of the inner wall of the right eye socket.
Fracture of medial orbital wall, right side, initial encounter for open fracture.This code describes a break in the bone of the medial wall of the right eye socket, where the fracture site is open, meaning there is a break in the skin exposing the fracture.
Example 1: A patient presents to the emergency room after being struck in the right eye by a baseball bat. A CT scan reveals an open fracture of the medial wall of the right orbit., A patient is involved in a motor vehicle accident and sustains multiple injuries, including an open fracture of the right medial orbital wall.The open wound is noted to be contaminated with debris from the crash., During a surgical procedure to remove a tumor near the right eye, the surgeon accidentally causes an iatrogenic open fracture of the medial orbital wall.
Documentation should include details of the injury mechanism, physical exam findings (e.g., periorbital edema, ecchymosis, enophthalmos, diplopia), imaging results (e.g., CT scan), and evidence of the open wound.If surgery is performed, operative notes should detail the procedure and any complications.
** For subsequent encounters for this fracture, use codes S02.831D (routine healing), S02.831G (delayed healing), S02.831K (nonunion), or S02.831S (malunion).
- Specialties:Emergency Medicine, Ophthalmology, Plastic Surgery, Maxillofacial Surgery, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Office