2025 ICD-10-CM code S02.832
Fracture of medial orbital wall, left side.
Medical necessity for treatment is based on the presence of a fracture confirmed through imaging. The specific treatment approach (conservative vs. surgical) is dictated by the severity of the fracture, displacement of bone fragments, involvement of surrounding structures, and presence of associated injuries.
The physician is responsible for diagnosing the fracture through physical examination and imaging studies (like CT scans), and determining the appropriate treatment, which may range from conservative management to surgical intervention.They also need to document the extent and type of fracture, associated injuries, treatment plan, and follow-up.
- S00-T88 Injury, poisoning and certain other consequences of external causes
- S02 Fracture of skull and facial bonesS02.8 Fractures of other specified skull and facial bonesS02.83 Fracture of medial orbital wallS02.832 Fracture of medial orbital wall, left side
In simple words: A broken bone on the inner side of the left eye socket.
A break in the bony structure forming the inner wall of the left eye socket.
Example 1: A patient presents to the ER after being struck on the left side of the face by a baseball.A CT scan reveals a fracture of the left medial orbital wall without any displacement of bone fragments or associated injuries. The patient is treated conservatively with pain medication and ice packs and sent home., During a motor vehicle accident, a patient sustained multiple facial injuries.Imaging reveals a comminuted fracture of the left medial orbital wall with entrapment of the medial rectus muscle.The patient requires surgery to repair the fracture and release the entrapped muscle., A boxer sustains a blow to the face during a match. They complain of double vision and pain around the left eye. Imaging shows a fracture of the left medial orbital wall extending into the orbital apex. The fracture is treated surgically to decompress the optic nerve and restore normal vision.
Documentation should include the cause of the injury, detailed physical exam findings, imaging results clearly indicating the location and type of fracture, associated injuries (soft tissue, ocular, intracranial), treatment provided (conservative or surgical), and follow-up plan.
** Diagnosis codes should be reported to the highest level of specificity. For example, if a fracture is both open and comminuted, the more specific code should be used.