Enophthalmos due to trauma or surgery, bilateral

This code signifies a sunken appearance of both eyes within the orbital cavity, specifically resulting from a prior traumatic injury or surgical intervention. It indicates a posterior displacement of the globe, affecting both eyes.

Apply this code when documentation clearly states bilateral enophthalmos is a sequela of trauma (e.g., orbital fracture) or a complication of ocular/orbital surgery. Physician notes must explicitly link the enophthalmos to the causative event.

• Ensure documentation specifies bilateral involvement; unilateral cases require different codes.
• Verify the etiology is explicitly stated as trauma or surgery; other causes (e.g., congenital, senile) are coded elsewhere.
• Code any underlying or associated conditions (e.g., orbital fracture) as primary if they are the reason for the encounter, with enophthalmos as a secondary diagnosis.