2025 ICD-10-CM code S04.1
(Active) Effective Date: N/A Revision Date: N/A Injury - Injuries to the head Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Injury of the oculomotor nerve (third cranial nerve).
Modifiers may be applicable depending on the circumstances of the injury and the services rendered.Consult appropriate coding guidelines for specific modifier usage.
Medical necessity for treatment of oculomotor nerve injury is established by the presence of symptoms impacting visual function, such as diplopia and ptosis, confirmed by clinical examination and, where appropriate, imaging studies.The severity of symptoms and impact on daily activities justify the level of intervention.
Diagnosis and treatment of oculomotor nerve injury falls under the responsibility of ophthalmologists and neurologists.Diagnosis relies on a thorough history, physical examination including neurological assessment of cranial nerves, and appropriate imaging studies to identify the cause and extent of the injury. Treatment options may range from conservative management with pain control to surgical intervention depending on the cause and severity of the damage.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code describes an injury to the nerve that controls eye movement and the eyelid.This injury can be caused by trauma or other problems. It can cause eye pain, blurry vision, the eye to point downward and outward, and a droopy eyelid. Doctors use imaging tests to diagnose the problem, and treatment might involve pain relievers or surgery.
S04.1 in the ICD-10-CM classification system denotes an injury to the oculomotor nerve, the third cranial nerve responsible for eye movement and eyelid elevation.This code encompasses trauma or disorders affecting the oculomotor nerve, leading to symptoms such as eye pain, double vision (diplopia), downward and outward eye deviation, and eyelid drooping (ptosis). Diagnosis involves patient history, symptom assessment, and imaging techniques like CT, MRI, and MRA. Treatment may include NSAIDs for pain relief and surgical nerve repair.
Example 1: A patient presents after a motor vehicle accident with complaints of double vision, a drooping eyelid, and difficulty moving their eye upward and inward.Imaging reveals a tear in the oculomotor nerve., A patient with a known history of diabetes mellitus develops sudden onset of double vision and ptosis.Examination reveals a third nerve palsy, sparing the pupil.This is consistent with a diabetic neuropathy of the oculomotor nerve., A patient presents with a complete oculomotor nerve palsy, including ptosis, mydriasis, and complete ophthalmoplegia, following a head injury. Imaging confirms a compression of the third cranial nerve by a hematoma.
Detailed patient history including mechanism of injury (if applicable), onset and progression of symptoms, presence of associated neurological deficits, and results of any imaging studies (CT, MRI, MRA).Documentation should also include details on the physical examination findings focusing on cranial nerve evaluation. If surgery is performed, operative notes are required.
** This code is used to report injury to the oculomotor nerve, regardless of the etiology.Additional codes should be used to describe the underlying cause and any associated conditions or complications.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Ophthalmology, Neurology, Neurosurgery
- Place of Service:Office, Hospital (Inpatient and Outpatient), Emergency Room, Ambulatory Surgical Center