2025 ICD-10-CM code S02.839A
Fracture of medial orbital wall, unspecified side, initial encounter for closed fracture.
Medical necessity for treatment is established by the presence of a fracture confirmed through imaging. The medical necessity for specific treatments, such as surgery, would depend on the severity of the fracture, presence of associated injuries (e.g., entrapped muscles, optic nerve damage), and clinical findings.
Physicians typically responsible for diagnosing and managing this type of injury include ophthalmologists, emergency medicine physicians, and potentially otolaryngologists (ENTs) or plastic surgeons depending on the severity and complexity of the fracture.
- S00-T88 Injury, poisoning and certain other consequences of external causes
- Injuries to the head (S00-S09)
In simple words: This code represents a closed fracture (a break that doesn't pierce the skin) of the inner wall of the eye socket, on an unspecified side.
Fracture of medial orbital wall, unspecified side, initial encounter for closed fracture. This code describes a break in the bone of the medial wall of the eye socket, which is the side closest to the nose.The side affected (left or right) is not specified. This code is used for the initial visit for a closed fracture, meaning the broken bone hasn't pierced the skin.
Example 1: A patient presents to the emergency room after being struck in the face with a baseball. Imaging reveals a closed fracture of the medial orbital wall., A patient falls and hits their head, resulting in a closed fracture of the medial orbital wall., During a motor vehicle accident, a patient sustains facial trauma resulting in a closed fracture of the medial orbital wall.
Documentation should include details of the injury mechanism, physical exam findings (e.g., periorbital ecchymosis, edema, diplopia), imaging results (e.g., CT scan, X-ray), and any associated injuries.Neurological examination findings are crucial to document.
** The code S02.839A specifically refers to a closed fracture.Open fractures of the medial orbital wall are classified under a different code. Be sure to code for any associated intracranial injury (S06.-) as needed.
- Payment Status: Active
- Specialties:Emergency Medicine, Ophthalmology, Otolaryngology, Plastic Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office