ICD 10 Coding Alert

Question: Our ophthalmologist evaluated an inpatient who was in a car accident. The patient said she felt fine except for some pain in her left eye where her face hit the steering wheel. The X-ray confirmed a fracture of the orbital roof on the left eye. Which diagnosis code applies?

New Jersey Subscriber

Answer: About 20 new diagnoses joined the ICD-10 code set for 2020 to reflect orbital fractures, including S02.12 (Fracture of orbital roof), which is the best option for this situation. This code expands out to seven characters to reflect the location of the fracture and whether you see the patient during the initial or subsequent encounter (or if you’re treating sequela).

In this case, you’re treating the left eye for an initial encounter, so the appropriate diagnosis code is S02.122A (Fracture of orbital roof, left side, initial encounter…). You should also add a code from ICD-10’s external causes of morbidity section to reflect the cause of the fracture. For instance, V89.2XXA (Person injured in unspecified motor-vehicle accident, traffic, initial encounter).