Inferior rectus muscle entrapment, right eye

This code describes a condition where the inferior rectus muscle of the right eye becomes trapped, often due to trauma such as an orbital fracture. This entrapment restricts the eye's movement, particularly upward gaze, and can lead to diplopia (double vision) and pain. The muscle itself is physically restricted, preventing its normal function.

Use this code when documentation explicitly states entrapment of the inferior rectus muscle affecting the right eye, typically following orbital trauma. Supporting documentation should include findings from imaging studies (e.g., CT scan) confirming muscle impingement and clinical signs of restricted ocular motility. This code is appropriate for both acute and chronic presentations of this specific entrapment.

• Ensure documentation specifies "entrapment" of the inferior rectus, not just paresis or paralysis, which would be coded differently.
• Verify the laterality is clearly documented as "right eye" to avoid miscoding.
• Always code the underlying cause, such as an orbital fracture (e.g., S02.1xxA), in addition to this code, following sequencing guidelines.