Fracture of orbital floor, left side
ICD-10 S02.32 is a billable code used to indicate a diagnosis of fracture of orbital floor, left side.
A fracture of the orbital floor, specifically on the left side, is a type of facial injury that occurs when the bony structure of the eye socket is compromised. This injury often results from blunt trauma, such as a fall, sports injury, or physical assault. The orbital floor is particularly susceptible to fractures due to its thin structure and the force exerted during impact. Symptoms may include pain, swelling, bruising around the eye, 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 surrounding structures. Management may include observation for minor fractures, while more severe cases may require surgical intervention to repair the fracture and restore normal function. Complications can include persistent diplopia, enophthalmos (sunken eye), and chronic pain. Accurate coding is essential for proper treatment reimbursement and tracking of injury patterns.
Documentation must include a detailed account of the injury mechanism, symptoms, and initial treatment provided.
Patients presenting with facial trauma after a fall or sports injury.
Ensure that all relevant symptoms, such as vision changes, are documented to support the diagnosis.
Operative reports must detail the surgical approach, findings, and any repairs made to the orbital floor.
Surgical intervention for significant fractures requiring reconstruction.
Document any complications or additional procedures performed during surgery.
Used when surgical intervention is performed for a left orbital floor fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
Common causes include blunt trauma from sports injuries, falls, physical altercations, and motor vehicle accidents.
Diagnosis typically involves a clinical examination followed by imaging studies such as CT scans to assess the fracture and any associated injuries.
Complications can include persistent diplopia, enophthalmos, and chronic pain, necessitating further evaluation and management.
