2025 ICD-10-CM code S02.839

Fracture of medial orbital wall, unspecified side.

Follow general ICD-10-CM coding guidelines. Use additional codes as needed to capture the cause of the injury (external cause codes from Chapter 20), associated intracranial injury (S06.-), or retained foreign body (Z18.-).Ensure documentation supports the use of this code and that the fracture is not open, as a separate code exists for open fractures (S02.839B).

Medical necessity for the diagnosis and treatment of a medial orbital wall fracture is established by the presence of the fracture itself, typically confirmed by imaging. Associated signs and symptoms such as pain, swelling, visual disturbances, or impaired eye movement would further support the medical necessity of intervention.

Clinicians responsible for diagnosing and treating injuries to the head, including ophthalmologists, emergency medicine physicians, and trauma surgeons, would use this code. Proper documentation of the injury, including imaging results, is crucial for accurate coding.

IMPORTANT For open fractures, use S02.839B. For specific laterality, use S02.831 (right) or S02.832 (left).For subsequent encounters or delayed healing, use S02.839D, S02.839G, S02.839K, or S02.839S as appropriate. Use additional code(s) from Chapter 20 to indicate cause of injury. Use additional code to identify any retained foreign body, if applicable (Z18.-).

In simple words: A break in the bone forming the inner wall of the eye socket, without specifying which eye.

Fracture of medial orbital wall, unspecified side. This code is used to document a fracture of the medial wall of the orbit, without specifying whether it is the right or left side.It is important to note that this code should be used for closed fractures.Open fractures of the medial orbital wall have separate codes (S02.839B). Additional codes may be necessary to fully describe the injury, such as those for associated intracranial injuries (S06.-) or retained foreign bodies (Z18.-).

Example 1: A patient presents to the emergency department after being struck in the face with a baseball. Imaging reveals a closed fracture of the medial orbital wall, but the side is not specified in the report.S02.839 is used to code the injury., A patient is involved in a motor vehicle accident and sustains multiple injuries, including a closed fracture to the medial orbital wall. The imaging report doesn't specify which side is affected. S02.839 is appropriate for this scenario., A physician reviews a patient's chart which indicates a fracture of the medial wall of the orbit due to an unspecified blunt force trauma. The side of the injury is not documented. S02.839 can be used in the absence of laterality information, assuming it is a closed fracture.

Documentation should include details of the injury mechanism, imaging findings confirming the fracture, and clinical examination notes describing the injury's extent. The physician's documentation must confirm the type of fracture whether its is a closed or open fracture.If the side is documented, the more specific codes should be used (S02.831 or S02.832).

** For injuries involving multiple regions of the orbit, refer to the guidelines provided in the Tabular List of Diseases and Injuries for proper coding.

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