2025 ICD-10-CM code S02.831K
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fractures of the orbit Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Subsequent encounter for fracture of the right medial orbital wall with nonunion.
Medical necessity is established when the patient presents with symptoms related to a nonunion fracture and requires further evaluation or treatment.This can include persistent pain, functional impairment, or the potential for complications such as infection or further bone displacement.The documentation must clearly demonstrate that the patient's symptoms and the nonunion fracture require the intervention being provided.
The clinical responsibility includes the diagnosis, treatment, and management of the nonunion fracture of the right medial orbital wall. This may involve imaging studies (such as X-rays or CT scans), consultations with specialists (such as ophthalmologists or maxillofacial surgeons), and potential surgical intervention or other therapeutic strategies aimed at achieving bone union.The physician's role involves evaluating the patient's condition, coordinating care with other healthcare professionals, educating the patient on the condition and treatment, and providing necessary follow-up care.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S00-T88 (Injury, poisoning and certain other consequences of external causes) > S00-S09 (Injuries to the head) > S02 (Fractures of skull and face bones)
In simple words: This code is used for a follow-up visit after a broken bone in the right medial orbital wall (part of the eye socket) hasn't healed properly.It means the broken bone isn't joining back together, and the patient needs further care.
This code signifies a subsequent encounter for a fracture of the right medial orbital wall that has not healed (nonunion).It indicates that the patient has already received initial treatment for the fracture and is now being seen for ongoing care related to the nonunion.This code should only be used after the initial encounter codes (S02.831A, S02.831B) have been used appropriately. Additional codes may be necessary to specify associated injuries or complications.
Example 1: A 30-year-old male sustained a right medial orbital wall fracture in a motor vehicle accident three months ago.He presents with persistent pain and limited eye movement.Imaging reveals nonunion of the fracture. S02.831K is used to describe this subsequent encounter., A 25-year-old female experienced a right medial orbital wall fracture during a sporting event. Initial treatment was provided, but subsequent imaging at six months post-injury demonstrates nonunion, requiring further intervention such as surgery. S02.831K is used., A 50-year-old male with a history of osteoporosis suffered a fall resulting in a fracture to the right medial orbital wall. Despite previous treatment, the fracture shows nonunion at a follow-up visit six months post-injury, leading to the use of S02.831K and potential referral to a specialist.
Detailed history of the initial injury and subsequent treatment, including operative reports, imaging studies (X-rays, CT scans),and documentation of clinical findings (pain, limited range of motion, visual impairment, etc.) should be present to accurately utilize code S02.831K.Follow-up examination notes are required.
** Always code the underlying cause of the fracture using codes from Chapter 20.This code is only for subsequent encounters after the initial fracture.
- Payment Status: Active
- Specialties:Ophthalmology, Oral and Maxillofacial Surgery, Emergency Medicine
- Place of Service:Office, Hospital, Ambulatory Surgical Center