Fracture of medial orbital wall, right side
ICD-10 S02.831 is a billable code used to indicate a diagnosis of fracture of medial orbital wall, right side.
A fracture of the medial orbital wall, specifically on the right side, typically occurs due to blunt trauma to the face, such as from sports injuries, falls, or motor vehicle accidents. The medial orbital wall is a thin bony structure that separates the orbit from the nasal cavity, making it susceptible to fractures when subjected to significant force. Symptoms may include diplopia (double vision), enophthalmos (sunken eye), and periorbital edema. Diagnosis is primarily through imaging studies, such as CT scans, which can reveal the extent of the fracture and any associated injuries to the surrounding structures. Management often involves observation for minor fractures, while more severe cases may require surgical intervention to repair the wall and restore orbital integrity. Complications can include persistent diplopia, orbital cellulitis, or vision loss if not properly addressed. Accurate coding is essential for appropriate reimbursement and tracking of injury patterns.
Documentation must include a detailed account of the injury mechanism, initial assessment findings, and any imaging results.
Patients presenting with facial trauma after a fall or sports injury, often requiring immediate imaging.
Ensure that all relevant symptoms and potential complications are documented to support the diagnosis.
Operative reports should detail the surgical approach, findings, and any repairs made to the orbital wall.
Surgical repair of a medial orbital wall fracture following trauma, with potential reconstruction of surrounding structures.
Accurate coding of surgical procedures performed in conjunction with the fracture repair is essential.
Used when surgical repair is performed for a medial orbital wall fracture.
Operative report detailing the procedure, findings, and any complications.
Ensure that the surgical approach and any additional procedures are documented.
A CT scan is the preferred imaging modality as it provides detailed views of the orbital structures and can identify associated injuries.
