Fracture of orbital floor, right side, sequela

This code signifies a fracture of the orbital floor (the bone forming the bottom of the eye socket) on the right side, where the patient is experiencing a late effect or complication of the initial injury. This could include persistent diplopia, enophthalmos, or chronic pain resulting from the original fracture.

Apply this code when documenting a patient presenting with a long-term consequence or residual condition directly attributable to a previously sustained right orbital floor fracture. Documentation should clearly state the sequela and link it to the prior injury, often seen in follow-up visits months or years after the initial trauma.

• Ensure documentation explicitly states "sequela" or describes a chronic condition resulting from the fracture.
• Do not use for acute fractures; those require codes from the initial encounter or subsequent encounter categories.
• Always sequence the sequela code first, followed by any additional codes describing the specific late effect (e.g., diplopia, enophthalmos).