Oclr lac w/o prolaps/loss of intraoc tissue, unsp eye, init

This code signifies a traumatic injury to the eye involving a cut or tear of the ocular tissues, but without any extrusion of internal eye structures or contents. It indicates that the specific eye affected (left or right) is not documented, and this is the first time the patient is being treated for this injury.

Use this code when documentation clearly states an ocular laceration without mention of prolapse of intraocular tissue, and the affected eye is not specified. This is appropriate for initial treatment encounters for such an injury, such as in an emergency department or initial ophthalmology visit.

• Ensure documentation explicitly denies prolapse or loss of intraocular tissue; otherwise, a more specific code may be warranted.
• If the affected eye (right or left) is documented, use the more specific code (S05.31XA or S05.32XA).
• Always confirm the encounter type is "initial" for the "A" seventh character.