Injury of optic nerve, unspecified eye, initial encounter

This code signifies damage to the optic nerve, the cranial nerve responsible for transmitting visual information from the retina to the brain, without specifying which eye is affected. The injury can result from various etiologies, including trauma, compression, or ischemia, leading to potential vision impairment.

Use this code when documentation indicates an optic nerve injury but does not specify laterality (left or right eye). This is appropriate for initial treatment of the injury. Supporting documentation should clearly state "optic nerve injury" without further detail regarding the affected eye.

• Avoid using this code if the documentation specifies the affected eye; instead, use the more specific S04.011A (right eye) or S04.012A (left eye).
• Ensure the "A" seventh character is appended for the initial encounter for active treatment of the injury.
• Always query the provider for laterality if not clearly documented to allow for more specific coding.