Fracture of medial orbital wall, left side, sequela

This code signifies a long-term complication or late effect resulting from a fracture of the medial wall of the left orbit. This typically involves issues such as enophthalmos, diplopia, chronic pain, or persistent cosmetic deformity that arise after the initial healing phase of the fracture.

Apply this code when documenting a patient presenting with a current sequela directly attributable to a previously sustained fracture of the left medial orbital wall. Documentation must clearly link the current condition to the old fracture and indicate that the acute phase of the fracture has passed.

• Requires a seventh character 'S' for sequela, indicating a complication or late effect of the original injury.
• Always sequence this code after the code describing the specific sequela (e.g., H53.2 for diplopia, H05.40 for enophthalmos).
• Ensure documentation explicitly states the laterality (left) and the specific orbital wall affected (medial).