Fracture of medial orbital wall, right side, sequela

This code signifies a long-term complication or late effect resulting from a fracture of the medial wall of the right orbit. It indicates that the initial injury has healed, but the patient continues to experience residual problems directly attributable to that past fracture. These sequelae could include chronic pain, vision impairment, diplopia, enophthalmos, or other persistent functional deficits.

Apply this code when documentation clearly indicates a current condition or symptom is a direct consequence of a previously sustained fracture of the right medial orbital wall. The patient's medical record should specify the causal link between the old injury and the present complaint. This code is appropriate for follow-up visits addressing these chronic issues, not for the initial acute injury.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) (e.g., chronic diplopia, enophthalmos).
• Ensure documentation explicitly states the "sequela of" or "due to old fracture" to support the use of this seventh character.
• Distinguish from initial encounter (A), subsequent encounter (D), or nonunion/malunion (K, P, Q) codes for fractures. This code is for late effects after healing.