In simple words: A break in the bone that forms the inner side of the eye socket, which side is unspecified. The skin is broken at the fracture site and it is the patient's first visit for this injury.

Fracture of medial orbital wall, unspecified side, initial encounter for open fracture

Example 1: A patient presents to the emergency room after being hit in the face with a baseball. Imaging reveals an open fracture of the medial orbital wall, unspecified side. This is the patient's first encounter for this injury, so S02.839B is the appropriate code., A patient sustains a deep laceration near the eye in a car accident. During surgical exploration, it's determined the medial orbital wall has also been fractured. Because the wound allows direct access to the fractured bone without surgical dissection, it is considered open and S02.839B would be used given this is the first time the injury is being addressed., An assault victim presents with multiple facial injuries. Among the injuries is a fractured medial orbital wall. Bone fragments are visible through the skin laceration, making this an open fracture. As it's the patient's initial visit for this condition, S02.839B is the correct code.

Documentation should include details of the injury mechanism, physical exam findings, imaging results (e.g., CT scan, X-ray), and treatment provided. The "open" nature of the fracture must be clearly documented, noting the presence of a skin laceration communicating with the fracture site.

** This code specifies the side of the injury as unspecified. More specific codes exist if the side is known (S02.831B for the right side and S02.832B for the left side).This code is for the initial encounter, if the patient is seen for subsequent encounters, other 7th character codes would be applied (e.g., D, G, K, S).