Unspecified open wound of left eyelid and periocular area
ICD-10 S01.102 is a billable code used to indicate a diagnosis of unspecified open wound of left eyelid and periocular area.
An unspecified open wound of the left eyelid and periocular area refers to a traumatic injury that results in a break in the skin or mucous membrane in the region surrounding the left eye. This type of injury can occur due to various mechanisms, including blunt trauma, lacerations, or penetrating injuries. The periocular area encompasses the eyelids, the skin surrounding the eyes, and may involve deeper structures such as muscles and nerves. Clinical presentation may include bleeding, swelling, pain, and potential impairment of vision depending on the severity and depth of the wound. Accurate assessment is crucial, as these injuries can lead to complications such as infection, scarring, or damage to the ocular structures. Management typically involves cleaning the wound, assessing for foreign bodies, and determining the need for suturing or further surgical intervention. Follow-up care is essential to monitor for signs of infection and proper healing.
Documentation must include a detailed description of the injury, mechanism of injury, and initial treatment provided.
Trauma cases involving sports injuries, accidents, or assaults leading to eyelid wounds.
Ensure that all relevant details about the injury and treatment are captured to support the coding.
Operative reports should detail the surgical procedure performed, including any repairs or interventions on the eyelid.
Surgical management of complex lacerations or reconstruction of the eyelid.
Document any complications or additional procedures performed during surgery.
Used when the open wound requires suturing or repair.
Document the size of the wound and the technique used for repair.
Ensure that the procedure is clearly linked to the diagnosis of the open wound.
Document the mechanism of injury, depth of the wound, any associated injuries, treatment provided, and follow-up care.
