Ocular laceration without prolapse of intraocular tissue

This code describes a traumatic injury to the eye involving a tear or cut in the ocular tissues, such as the cornea or sclera, where no internal eye structures have extruded through the wound. It indicates a full-thickness or partial-thickness laceration of the globe without prolapse of the uvea, vitreous, or retina.

Use this code for patients presenting with a confirmed laceration of the eyeball where examination clearly indicates that no intraocular contents have prolapsed. Documentation should specify the presence of a laceration and explicitly state the absence of prolapsed tissue. This code is appropriate for injuries like corneal lacerations or scleral lacerations without uveal exposure.

• Differentiate carefully from codes indicating globe rupture with prolapse; the absence of prolapse is key.
• Ensure documentation specifies the location of the laceration (e.g., cornea, sclera) if known, as more specific codes may exist in other code sets.
• Always review operative reports or ophthalmology notes for explicit statements regarding the presence or absence of intraocular tissue prolapse.