Fracture of orbital floor, unspecified side
ICD-10 S02.30 is a billable code used to indicate a diagnosis of fracture of orbital floor, unspecified side.
The orbital floor fracture, also known as a blowout fracture, occurs when there is a fracture of the bony structure that forms the base of the eye socket. This type of injury is often the result of blunt trauma to the face, such as from a fistfight, sports injury, or motor vehicle accident. The fracture can lead to various complications, including enophthalmos (sunken eye), diplopia (double vision), and potential damage to the ocular structures. Patients may present with symptoms such as periorbital swelling, bruising, and difficulty moving the eye. 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. Management may range from conservative treatment with ice and pain management to surgical intervention for more severe cases. Accurate coding is essential for proper 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 facial trauma from falls, sports injuries, or assaults.
Ensure that all relevant symptoms and potential complications are documented to support the diagnosis.
Operative reports must detail the surgical approach, findings, and any repairs made to the orbital floor.
Surgical management of significant orbital floor fractures requiring reconstruction.
Accurate coding of surgical procedures performed in conjunction with the fracture repair.
Used when surgical intervention is required for an orbital floor fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
S02.30 is used for an unspecified side of the orbital floor fracture, while S02.31 specifies a fracture on the right side. Accurate documentation of the side of the injury is crucial for correct coding.
