2025 ICD-10-CM code S02.831G
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fracture of medial orbital wall Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Subsequent encounter for fracture of the right medial orbital wall with delayed healing.
Modifiers may apply depending on the circumstances of the visit and services rendered. Consult local payer guidelines.
Medical necessity for continued care is established by documentation of delayed healing, presence of symptoms (pain, swelling, etc.), and the physician's plan for managing the complication. The necessity is supported by clinical findings and the need for further intervention to ensure proper healing and prevent long-term complications.
The clinical responsibility involves monitoring the healing progress of the fracture, assessing for complications, and providing appropriate treatment to facilitate proper healing.This may include imaging studies, pain management, and follow-up examinations. If the fracture is not healing appropriately, surgical intervention or other specialized care may be necessary.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S00-S09 (Injuries to the head)
In simple words: This code is for a follow-up visit after a broken bone in the right eye socket that's not healing as quickly as expected. The doctor will continue to monitor and treat the healing process.
This code signifies a subsequent encounter for a fracture of the right medial orbital wall, characterized by delayed healing.It indicates that the initial fracture has not healed within the expected timeframe and requires further medical attention or monitoring. This code is used for subsequent visits related to the ongoing management of this specific fracture, not for initial diagnosis.Additional codes may be necessary to indicate the cause of the injury or any associated complications.
Example 1: A patient presents for a follow-up appointment after a right-sided medial orbital wall fracture.Imaging reveals delayed healing. The physician orders additional imaging and discusses options for accelerating the healing process., A patient sustained a right medial orbital wall fracture in a motor vehicle accident.Several weeks after the initial treatment, the patient experiences increased pain and swelling.A subsequent examination reveals delayed healing, and the code S02.831G is used to reflect the delayed healing during this follow-up visit., A patient with a history of right medial orbital wall fracture is seen for a routine follow-up appointment. The fracture has not healed properly and shows signs of delayed healing. The physician orders further imaging and a consultation with an ophthalmologist.Code S02.831G is utilized to reflect this ongoing delayed healing.
* Detailed history of the initial injury and subsequent treatment.* Documentation of the initial diagnosis and imaging findings (e.g., X-ray, CT scan).* Notes indicating the timeline of the healing process.* Findings from the current examination and any new imaging studies.* Documentation of any complications or associated injuries.* Physician's plan for ongoing management of the delayed healing.
** This code is specifically for subsequent encounters where delayed healing is documented.The initial encounter would be coded differently depending on the initial presentation and the nature of the fracture (closed vs. open).Careful documentation is essential for appropriate coding.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Ophthalmology, Plastic Surgery, Oral and Maxillofacial Surgery
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital