Fracture of orbital roof, right side, sequela

This code signifies a long-term complication or late effect stemming from a previous fracture of the superior aspect of the right eye orbit. It indicates that the initial injury has healed, but residual issues directly attributable to that fracture are now present. This could include chronic pain, vision impairment, or cosmetic deformity.

Apply this code when documentation clearly links a current condition or symptom to a previously sustained fracture of the right orbital roof. This code is appropriate for follow-up encounters addressing persistent problems after the acute phase of the fracture has passed. Supporting documentation should specify "sequela" or "late effect" and explicitly state the right side.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) (e.g., chronic pain, diplopia).
• Ensure the medical record explicitly states "sequela" or "late effect" of the right orbital roof fracture.
• Do not use this code for acute or active fractures; those require codes from the initial encounter or subsequent encounter categories.