2025 ICD-10-CM code S02.831S
Sequela of fracture of medial orbital wall, right side.
Medical necessity must be established by demonstrating the causal relationship between the original fracture and the current symptoms. The documentation should clearly explain why the sequela of the fracture requires continued medical care or intervention.
The physician is responsible for documenting the details of the original fracture, the specific long-term effects the patient is experiencing, and how these effects impact the patient's current health status.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code indicates lasting problems from a previous fracture of the inner bone of the right eye socket.
This code describes the long-term consequences or residual effects due to a past fracture of the medial wall of the right eye socket.
Example 1: A patient presents with persistent double vision (diplopia) and limited eye movement following a healed fracture of the right medial orbital wall sustained in a car accident several months prior., A patient experiences chronic pain and numbness in the right cheek area as a result of a previous medial orbital wall fracture, impacting their quality of life., A patient develops enophthalmos (sunken eye) on the right side after a medial orbital wall fracture, which is now healed, requiring reconstructive surgery.
Documentation should include details about the original fracture, including date of injury, type of fracture, and initial treatment. The current long-term effects should be specifically described, such as diplopia, pain, numbness, or enophthalmos. The impact of these effects on the patient's daily life and functional abilities should also be documented.
** The "S" at the end of the code signifies that it describes a sequela (late effect) of an injury. This code should not be used to describe the acute phase of the fracture.
- Payment Status: Active
- Specialties:Ophthalmology, Plastic Surgery, Maxillofacial Surgery
- Place of Service:Office, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Outpatient Hospital