Fracture of medial orbital wall, left side
ICD-10 S02.832 is a billable code used to indicate a diagnosis of fracture of medial orbital wall, left side.
A fracture of the medial orbital wall, specifically on the left side, typically results from blunt trauma to the face, such as from sports injuries, falls, or vehicular accidents. The medial orbital wall is a thin bone that separates the orbit from the nasal cavity, making it susceptible to fractures during trauma. Symptoms may include diplopia (double vision), enophthalmos (sunken eye), and periorbital edema (swelling around the eye). Diagnosis is primarily through imaging studies, such as CT scans, which can reveal the extent of the fracture and any associated injuries to surrounding structures. Management often involves observation for minor fractures, while more severe cases may require surgical intervention to repair the fracture and restore orbital integrity. Complications can include persistent diplopia, vision loss, or chronic pain if not properly managed. Accurate coding requires thorough documentation of the mechanism of injury, clinical findings, and any surgical procedures performed.
Documentation must include a detailed account of the injury mechanism, clinical findings, and any imaging performed.
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 coding.
Operative reports must detail the surgical approach, findings, and any repairs made to the orbital wall.
Surgical intervention for significant fractures requiring reconstruction or repair.
Accurate coding of surgical procedures performed in conjunction with the fracture repair is essential.
Used when surgical intervention is performed to repair the fracture.
Operative report detailing the procedure, findings, and any materials used.
Ensure that the surgical approach and any complications are documented.
Documenting the mechanism of injury is crucial for accurate coding and to support the medical necessity of the treatment provided. It helps differentiate between various types of fractures and associated injuries.
