2025 ICD-10-CM code S02.839S
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fractures of the orbit Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Sequela of fracture of the medial orbital wall, unspecified side.
Modifiers may be applicable depending on the specific circumstances of the encounter and the services provided.Consult current coding guidelines for details.
Medical necessity for coding S02.839S is established by the presence of persistent symptoms or complications directly related to the healed fracture of the medial orbital wall. The symptoms must be clinically significant and impact the patient's functionality or quality of life.Supporting documentation, such as imaging findings and detailed clinical notes, is essential to establish medical necessity.
The clinical responsibility involves documenting the healed fracture and any persistent sequelae. This may include a thorough ophthalmologic examination, imaging studies (CT scan or MRI), and a comprehensive assessment of the patient's symptoms and functional limitations.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S00-S09 (Injuries to the head)
In simple words: This code is used when someone has had a broken bone in the eye socket wall that has healed, but they still have problems because of the injury.It doesn't say which eye socket was affected.
This code signifies a late effect (sequela) following a fracture of the medial wall of the orbit, without specification of the affected side.It indicates that the initial fracture has healed, but residual effects or complications persist.This code should be used when the patient is experiencing ongoing problems related to the healed fracture, such as visual disturbances, pain, or cosmetic issues.Additional codes may be required to specify the nature of the sequela and any associated conditions.
Example 1: A patient presents with persistent double vision (diplopia) six months after a motor vehicle accident resulting in a healed fracture of the medial orbital wall.The physician documents the healed fracture and the persistent diplopia.S02.839S is used to code the sequela, and an additional code is used for the diplopia., A patient reports chronic pain and numbness in the area around the eye one year after sustaining a fracture of the medial orbital wall during a sports injury.The physician's documentation includes imaging studies showing a healed fracture and notes the persistent pain and paresthesia.S02.839S is used to reflect the sequela, with additional codes for chronic pain and paresthesia., A patient who underwent surgical repair for a medial orbital wall fracture several months prior is experiencing ongoing cosmetic deformity.The physician documents the healed fracture and the persistent cosmetic issue. S02.839S is utilized along with a code for the cosmetic deformity.
* Thorough history and physical examination focusing on the eye and surrounding structures.* Imaging studies (CT scan or MRI) to document the healed fracture and any associated anomalies.* Documentation of persistent symptoms and their impact on the patient's daily activities.* Evidence of the initial fracture and its treatment.
** Always refer to the latest official ICD-10-CM coding guidelines for the most up-to-date information and coding conventions.This information is for guidance only and should not be considered a substitute for professional medical coding advice.
- Payment Status: Active
- Specialties:Ophthalmology, Neurosurgery, Plastic Surgery, Emergency Medicine
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital