Unspecified enophthalmos, unspecified eye

This code signifies a sunken appearance of the eyeball within the orbit, where the specific cause of the enophthalmos is not documented. It indicates an inward displacement of the globe without further detail regarding the etiology or the affected eye.

This code is appropriate when documentation clearly states "enophthalmos" but lacks information about the underlying cause (e.g., trauma, orbital fat atrophy, systemic disease) or laterality. It should be used when the physician has not specified whether the condition affects the right, left, or both eyes.

• Avoid using this code if the cause of enophthalmos is known; instead, code the specific etiology.
• Do not use if laterality (right, left, or bilateral) is documented; choose a more specific code from the H05.4 series.
• Query the provider for more specific documentation regarding the cause and laterality of the enophthalmos whenever possible.