Superior rectus muscle entrapment, right eye

This code signifies a condition where the superior rectus muscle of the right eye is physically restricted or trapped, often due to trauma or orbital fracture. This entrapment limits the eye's movement, particularly upward gaze, and can lead to diplopia and strabismus.

Use this code when documentation explicitly states superior rectus muscle entrapment affecting the right eye. This diagnosis is typically supported by imaging studies (e.g., CT scan) demonstrating muscle incarceration and clinical findings of restricted ocular motility. It is commonly seen following orbital floor or medial wall fractures.

• Ensure laterality is clearly documented as "right eye" to support this specific code.
• Distinguish from paresis or paralysis of the superior rectus muscle, which would be coded differently (e.g., H49.xx).
• Always sequence this code after any underlying cause, such as an orbital fracture (e.g., S02.1xxA).