Your Step-by-Step Guide to ICD-10-CM Coding of Orbital Fractures

Thu, Jan 16, 2020 --

ICD-10, Skill Sharpener

ICD-10-CM coding for orbital fracture

ICD-10-CM 2020 added dozens of new codes for orbital fractures, which are breaks in the bones surrounding the eye. To help you get to the correct code faster, follow these steps for orbital fracture coding.

1. Check the Orbital Fracture Location

Your new ICD-10-CM 2020 options for orbital fractures allows you to identify the location more specifically when you assign your code. You’ll choose from the subcategories below based on the location information you have. Of all these subcategories, only S02.3- is not new for 2020.

  • Roof: S02.12- (Fracture of orbital roof)
  • Floor: S02.3- (Fracture of orbital floor)
  • Medial wall: S02.83- (Fracture of medial orbital wall)
  • Lateral wall: S02.84- (Fracture of lateral orbital wall)
  • Unspecified: S02.85- (Fracture of orbit, unspecified)

2. Determine Which Side Is Affected

Each of these orbital fracture ICD-10-CM codes requires seven characters to be complete and reportable. Payers will not accept incomplete codes on claims.

For all of the subcategories listed above (except unspecified subcategory S02.85-), the next character in the code is based on whether the side involved is the right, left, or unspecified. One trap to avoid is assuming you know which digit represents an unspecified side.

S02.12-, S02.83-, S02.84-: For orbital fracture codes where side is represented by the 6th character you use 9 to indicate the side is unspecified:

  • 1, right
  • 2, left
  • 9, unspecified

S02.3-: For the orbital floor fracture codes, side is indicated by the 5th character. You use 0 to show the side is unspecified:

  • 0, unspecified
  • 1, right
  • 2, left

The good news is that for orbital fracture coding, your documentation is likely to show the side involved, so you should not have to use the unspecified codes often. If you do, plan some clinical documentation improvement training for your providers on the importance of including the side involved.

3. Use Encounter and Fracture Type for 7th Character

For all of these orbital fracture ICD-10-CM codes, you have six options for the 7th character, and that 7th character bundles in both the type of encounter and the type of fracture.

  • A, initial encounter for closed fracture
  • B, initial encounter for open fracture
  • D, subsequent encounter for fracture with routine healing
  • G, subsequent encounter for fracture with delayed healing
  • K, subsequent encounter for fracture with nonunion
  • S, sequela

To help you choose among those characters, you have to understand when they apply.

Open/closed fracture: “A fracture not indicated as open or closed should be coded to closed,” according to a note conveniently placed with category S02.- (Fracture of skull and facial bones). This rule is also in the 2020 ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.19.c.

Encounter: That same area of the ICD-10-CM Official Guidelines explains initial and subsequent encounters.

You should choose an initial encounter code (A or B) if the patient is receiving active treatment for the fracture. If the patient delayed seeking treatment for a fracture or nonunion, the initial encounter codes are still appropriate.

Subsequent encounter characters D, G, and K are appropriate after active treatment is completed and the patient presents for routine care during healing or recovery.

Use the sequela character (S) when a patient presents for treatment of a condition produced by the fracture after the acute phase of the injury is over. Usually, you’ll report the code for the sequela condition first, and then report the sequela code, according to the ICD-10-CM Official Guidelines, Section I.B.10.

4. Bring It All Together

Once you’ve gathered all the information for your code, you need to select the correct code. You can use this checklist with options to be sure you have the required points.

Orbital Fracture ICD-10-CM Coding Checklist

Location

Roof

Floor

Medial wall

Lateral Wall

Unspecified

Side

Right

Left

Unspecified

Encounter/Fracture Type

Initial encounter

Closed fracture

Open fracture

Subsequent encounter

Routine healing

Delayed healing

Nonunion

Sequela

Keep in mind: To reach seven characters, the codes in S02.3- require an X placeholder in the 6th character space. An example is S02.31XA (Fracture of orbital floor, right side, initial encounter for closed fracture).

5. Apply the Notes for Your Code

Before you make final code assignments on your claim, you must check the notes ICD-10-CM includes for your code. These notes may be anywhere from the chapter level to the code level, so you have to be thorough when you check. (SuperCoder ICD-10-CM code details pages list all guidelines that apply to that ICD-10-CM code in one place.)

For the orbital fracture codes, there are Excludes1 and Excludes2 notes that you should review. The notes essentially make sure you know not to report orbital fracture codes for multiple locations unless the documentation shows fractures in each location. For instance, S02.1- (Fracture of base of skull), which includes orbital roof fracture subcategory S02.12-, has an Excludes2 note listing lateral orbital wall (S02.84-), medial orbital wall (S02.83-), and orbital floor (S02.3-).

What About You?

What tips do you have for simplifying fracture ICD-10-CM coding?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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