Fracture of lateral orbital wall, right side, sequela

This code signifies a long-term complication or late effect stemming from a previous fracture of the outer bony wall of the right eye socket. It indicates that the initial injury has healed, but residual issues related to that fracture persist. These sequelae could include chronic pain, vision impairment, enophthalmos, or diplopia.

Apply this code when documentation clearly indicates a current condition or symptom directly resulting from a previously healed fracture of the right lateral orbital wall. This is appropriate for follow-up encounters addressing ongoing problems attributable to the old injury, not for the initial acute fracture treatment. Documentation should specify the causal link between the prior fracture and the current sequela.

• Always sequence the sequela code first, followed by codes for the specific manifestations of the sequela (e.g., chronic pain, diplopia).
• Ensure the documentation explicitly states "sequela," "late effect," or describes a condition directly resulting from a past fracture.
• Do not use this code for acute or active fractures; those require codes from the S02.841- series without the "S" seventh character.