Neurosurgery Coding Alert

Question: Encounter notes indicate that a patient suffered a fracture of the right medial orbital wall. What is the correct ICD-10 code for this injury?

Ohio Subscriber

Answer: You’ll have to go all the way to the seventh character to choose the most accurate ICD-10 code for this patient. First, choose S02.831- (Fracture of medial orbital wall, right side) as the base, six-character code for the fracture.

Don’t stop there: Once you’ve chosen S02.831- as your diagnosis, you’ve just one more step to completion. Choose one of the following seventh-character options for the patient, depending on encounter specifics:

• A = initial encounter for closed fracture
• B = initial encounter for open fracture
• D = subsequent encounter for fracture with routine healing
• G = subsequent encounter for fracture with delayed healing
• K = subsequent encounter for fracture with nonunion
• S = sequela

Example: So let’s say the visit is the patient’s first to your practice for the injury and the fracture is closed. You would report S02.831A (Fracture of medial orbital wall, right side, initial encounter for closed fracture) as your final diagnosis.