Unspecified enophthalmos, bilateral

This code describes a condition where both eyeballs are abnormally recessed into the orbital cavity, but the underlying cause of this recession is not documented. Enophthalmos can be a sign of various underlying systemic or localized conditions affecting the orbital contents or bony structure.

Use this code when documentation clearly indicates bilateral enophthalmos without specifying the etiology. This is appropriate when the provider has noted the physical finding but has not yet determined or documented the cause, or when the cause is truly unknown.

• Avoid using this code if a specific cause for the enophthalmos (e.g., orbital fracture, fat atrophy) is documented; instead, code the underlying condition.
• Always query the provider for clarification if the cause of enophthalmos is suspected but not explicitly stated.
• Distinguish from exophthalmos (protrusion of the eyeball), which has a different set of codes.