2025 ICD-10-CM code S02.831D
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fractures of the orbital wall Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Subsequent encounter for fracture of the medial orbital wall, right side, with routine healing.
Modifiers might be applicable based on the circumstances of the visit and services provided.Consult official modifier guidelines.
The medical necessity for this subsequent encounter lies in the need to monitor the healing of the fracture and address any complications. Regular follow-up visits allow for early detection of delayed healing, infection, or other issues, enabling prompt intervention and improving patient outcomes.
The clinical responsibility includes the initial diagnosis and treatment of the orbital wall fracture, along with subsequent follow-up visits to assess the healing process. This would typically involve a physician specializing in ophthalmology, otolaryngology, or plastic surgery, depending on the extent of the injury and the need for surgical intervention or reconstruction.
- Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code is for a follow-up visit after a broken bone in the eye socket on the right side.The doctor is checking to see if the bone is healing normally.
This ICD-10-CM code signifies a subsequent encounter for a fracture of the medial orbital wall on the right side, where the healing process is progressing as expected.It indicates that the initial fracture has been treated, and the patient is being monitored for proper healing. This code should only be used after an initial encounter code (such as S02.831A or S02.831B) has been used to document the initial diagnosis and treatment.
Example 1: A 35-year-old male presents for a follow-up appointment three weeks after sustaining a right-sided medial orbital wall fracture in a sports-related injury.The fracture shows satisfactory healing with no complications.S02.831D is used to document this subsequent encounter., A 22-year-old female sustained a right-sided medial orbital wall fracture in a motor vehicle accident and underwent surgical repair.At her six-week post-operative appointment, the fracture shows good alignment and healing.S02.831D is appropriate for this visit., A 60-year-old male with a history of osteoporosis fell and fractured his right medial orbital wall. He presents for a follow-up appointment, and imaging shows signs of delayed healing. Although S02.831D may be part of the coding, additional codes may be necessary to document the delayed healing.
Detailed medical history including the mechanism of injury, initial treatment (if any), and date of injury.Radiological imaging (CT scan, X-ray) showing the fracture and evidence of healing.Physician's notes documenting the patient's examination and assessment of healing progress.
** This code is for subsequent encounters only.Use appropriate initial encounter codes (S02.831A, S02.831B) for the initial diagnosis and treatment of the fracture. Always code to the highest level of specificity.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Ophthalmology, Otolaryngology, Plastic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center