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2025 ICD-10-CM code S02.839D

Subsequent encounter for fracture of the medial orbital wall, unspecified side, with routine healing.

Always use the appropriate seventh character to specify the encounter type (A, B, D, G, K, S).Use additional codes to specify laterality (right or left side) if known and to identify any retained foreign body (Z18.-) or associated intracranial injury (S06.-).

Medical necessity is established by the need for follow-up care to monitor the healing of the fracture. This includes evaluating the progress of bone healing, assessing for complications such as infection or malunion, and managing any associated symptoms.

The clinical responsibility includes the initial assessment of the healing progress, imaging review if necessary, monitoring for complications (infection, pain management), and patient education.

IMPORTANT Related codes include S02.839A (initial encounter, closed fracture), S02.839B (initial encounter, open fracture), S02.839G (subsequent encounter, delayed healing), S02.839K (subsequent encounter, nonunion), and S02.839S (sequela).Additional codes may be necessary to specify the laterality (right or left) if known and to indicate any associated intracranial injury (S06.-) or retained foreign body (Z18.-).

In simple words: This code is used for a doctor's visit after an eye socket bone fracture. The healing is going well as expected, and the doctor is checking on the progress.

This code signifies a subsequent encounter for a patient with a fracture of the medial orbital wall, where the healing process is progressing as expected.The side of the fracture is unspecified.This is a code for a follow-up visit after the initial treatment of the fracture and is used when the healing is considered routine.

Example 1: A patient presents for a follow-up appointment three weeks after sustaining a medial orbital wall fracture. The fracture shows satisfactory healing with no signs of infection or complications.This code would be used for this visit., A patient is seen in the emergency department for a medial orbital wall fracture. Imaging confirms the fracture. The patient is subsequently seen by an ophthalmologist and undergoes surgical repair.S02.839A or S02.839B would be used for the initial visit. Subsequent visits would use S02.839D for routine healing or other appropriate codes for delayed healing or complications., A patient with a known medial orbital wall fracture presents with complaints of persistent pain and limited eye movement.Physical examination and imaging reveal delayed healing.In this case, a code other than S02.839D (e.g. S02.839G) would be used.

The documentation must clearly indicate that this is a subsequent encounter for a previously diagnosed and treated medial orbital wall fracture.The documentation should include details of the healing status, any complications, and the overall clinical assessment.Imaging reports (X-rays, CT scans) should be available if obtained.

** The unspecified laterality (side) in this code does not affect the coding, but additional documentation should specify the laterality if it is known.

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