Fracture of orbital floor, unspecified side, sequela

This code represents a fracture of the orbital floor, the thin bone forming the bottom of the eye socket, where the fracture is no longer acute but is causing ongoing problems or conditions. It signifies a long-term effect or complication resulting from a previously sustained orbital floor fracture.

Use this code when documenting a patient presenting with a current condition or symptom directly attributable to a past orbital floor fracture, such as enophthalmos, diplopia, or chronic pain. Documentation should clearly link the current complaint to the historical fracture and indicate that the fracture itself is no longer in the acute healing phase.

• Ensure documentation explicitly states the current condition is a "sequela" or "due to a previous fracture."
• Do not use this code for acute or initial treatment of an orbital floor fracture; use the appropriate acute fracture code.
• Always code the specific sequela (e.g., diplopia, enophthalmos) first, followed by this sequela code.