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v1.0.0
ICD-10 Guide
DiagnosesOrbital Fracture

Orbital Fracture

ICD-10 Coding for Orbital Fracture(S02.122A, S02.832A)

PRIMARY SPECIALTYOphthalmology
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Orbital Fracture?
Essential facts and insights about Orbital Fracture

Key Clinical Considerations:

  • Periorbital swelling and bruising
  • Diplopia or vision changes
  • Enophthalmos or exophthalmos
  • Decreased ocular motility
  • Numbness in the distribution of the infraorbital nerve

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including mechanism of injury
  • Detailed physical examination findings
  • Results of imaging studies (CT scan preferred)
  • Assessment of visual acuity and ocular motility
  • Treatment plan and follow-up recommendations

Coding Guidelines

Usage Guidelines & Examples

  • Use S02.1 for isolated orbital floor fractures; S02.2 for wall fractures.
  • Common errors include using unspecified codes or failing to document the mechanism of injury.

Code Exclusions

Important Exclusions

  • Fractures of the skull base
  • Fractures associated with other facial injuries

Related ICD-10 Codes

Primary Codes
S02.1
Fracture of orbital floor
S02.2
Fracture of orbital wall
S02.3
Fracture of orbital roof
Ancillary Codes
W21.02XA
V89.2XXA
Differential Codes
S02.3-
S02.84-

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Ophthalmology

Specialty Applications

  • Adults and children with trauma-related injuries
  • Emergency departments, outpatient clinics, and surgical settings

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What are the documentation requirements?

Document the mechanism of injury, clinical findings, imaging results, and treatment plan.

What are the billing considerations?

Ensure accurate coding based on the specific type of fracture and associated injuries.