Radiology Coding Alert

Question: I’m coding a preoperative magnetic resonance imaging (MRI) scan for a revision of a two-year-old right orbital fracture resulting in enophthalmos and orbital pain. Impression reveals an old orbital fracture. What diagnosis codes should I report?

Arizona Subscriber

Answer: In coding this MRI scan, you’ve got to take the following three variables into consideration:

• Preoperative scan,
• Old orbital fracture, and
• Current manifestations.

Whenever you’re looking at a symptom or condition manifesting from an old injury such as an orbital fracture, your next step is to confirm that the current manifestation is a sequela of the fracture. ICD-10-CM guidelines define a sequela as “the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” Furthermore, the ICD-10-CM guidelines explain that there is no definitive time frame that needs to be met in order for a current condition to qualify as a sequela of a past injury or condition.

Based on this definition, the enophthalmos and orbital pain certainly qualify as sequela of the old orbital fracture. ICD-10-CM explains further how you should sequence sequela coding in this particular example:

“Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.”

In this case, you’ll be coding the enophthalmos and orbital pain as the underlying conditions with the sequela as a secondary diagnosis. Since enophthalmos may manifest asymptomatically, it’s important to also include orbital pain. The coding will go as follows:

• H05.421 (Enophthalmos due to trauma or surgery, right eye)
• H57.11 (Ocular pain, right eye)
• S02.31XS (Fracture of orbital floor, right side, sequela).