Enophthalmos due to trauma or surgery, unspecified eye

This code signifies the posterior displacement of the eyeball within the orbit, specifically when caused by an injury or a surgical intervention. It indicates that the affected eye is not specified in the medical record.

Apply this code when documentation clearly states enophthalmos resulting from trauma (e.g., orbital fracture) or a post-surgical complication, and the laterality of the affected eye is not documented. Supporting documentation would include operative reports, emergency department notes, or ophthalmology consultation notes detailing the cause and condition.

• Ensure the documentation explicitly links the enophthalmos to either trauma or surgery; otherwise, consider other enophthalmos codes.
• Avoid using this code if the affected eye (right or left) is specified; instead, use H05.421 or H05.422.
• Always sequence an external cause code (e.g., V00-Y99) first if the enophthalmos is due to an acute injury.