Fracture of orbital roof, unspecified side
ICD-10 S02.129 is a billable code used to indicate a diagnosis of fracture of orbital roof, unspecified side.
A fracture of the orbital roof refers to a break in the bony structure that forms the upper boundary of the eye socket. This type of fracture is often associated with trauma to the face, such as from falls, sports injuries, or vehicular accidents. The orbital roof is critical for protecting the eye and supporting the surrounding structures. Symptoms may include periorbital swelling, bruising, 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. Management may range from conservative treatment, including observation and pain management, to surgical intervention for more severe cases where there is significant displacement or involvement of the eye. Complications can include persistent diplopia, enophthalmos (sunken eye), or chronic pain. Accurate coding is essential for proper reimbursement and tracking of injury patterns.
Detailed documentation of the mechanism of injury, initial assessment findings, and imaging results.
Patients presenting with facial trauma after falls or accidents.
Ensure that all relevant injuries are documented to avoid undercoding.
Operative reports detailing the surgical approach, findings, and any repairs made.
Surgical intervention for displaced fractures or those causing significant ocular symptoms.
Document any complications or additional procedures performed during surgery.
Used when surgical intervention is required for an orbital roof fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
Common causes include blunt trauma from falls, sports injuries, or vehicular accidents. The mechanism of injury is crucial for diagnosis and management.
