Fracture of orbital roof, left side
ICD-10 S02.122 is a billable code used to indicate a diagnosis of fracture of orbital roof, left side.
A fracture of the orbital roof, specifically on the left side, is a type of craniofacial injury that occurs when there is a break in the bony structure forming the upper part of the eye socket. This injury is often the result of blunt trauma, such as from a fall, sports injury, or motor vehicle accident. The orbital roof is critical for protecting the eye and supporting the surrounding structures. Symptoms may include periorbital swelling, bruising, diplopia (double vision), and potential vision impairment. Diagnosis typically involves a thorough clinical examination and imaging studies, such as CT scans, to assess the extent of the fracture and any associated injuries to the eye or surrounding tissues. Management may range from conservative treatment, including observation and pain management, to surgical intervention for more severe fractures that compromise the eye or require reconstruction. Complications can include persistent diplopia, enophthalmos (sunken eye), or chronic pain. Accurate coding is essential for proper treatment reimbursement and tracking of injury patterns.
Documentation must include a detailed account of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with blunt trauma to the face, often following sports injuries or accidents.
Ensure that all associated symptoms, such as visual disturbances, are documented to support the diagnosis.
Operative reports should detail the surgical approach, findings, and any reconstruction performed.
Surgical repair of the orbital roof following significant trauma or fracture.
Document any pre-existing conditions that may affect surgical outcomes or recovery.
Used when surgical intervention is performed for an orbital roof fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
Laterality is crucial in coding as it specifies the side of the injury, which impacts treatment and management. Accurate documentation ensures proper coding and reimbursement.
