Fracture of medial orbital wall, left side, 7thK

This code signifies a fracture of the medial wall of the left orbit that has failed to heal properly after initial treatment. It indicates that the patient is presenting for ongoing management of this nonunion, rather than for the initial injury or routine follow-up of a healing fracture.

Apply this code when a patient with a previously diagnosed left medial orbital wall fracture presents for care related to the nonunion of that fracture. Documentation should clearly state "nonunion" and specify the left side and medial orbital wall. This code is appropriate for subsequent encounters, such as follow-up appointments, surgical interventions for the nonunion, or evaluation of complications arising from the nonunion.

• Ensure documentation explicitly states "nonunion" and specifies the left medial orbital wall.
• This code requires a 7th character "K" for subsequent encounter with nonunion; do not confuse with "D" for subsequent encounter with routine healing or "G" for subsequent encounter with delayed healing.
• Always sequence this code as the primary diagnosis if the nonunion is the focus of the encounter.