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S01.111A

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S01.111A

Short Definition

Laceration without foreign body of the right eyelid and periocular area, initial encounter — a full or partial thickness wound of the right eyelid skin, lid margin, tarsus, or periocular soft tissue, with no retained foreign material, being evaluated and/or treated for the first time.

Long Clinical Definition

S01.111A describes an acute traumatic laceration of the right eyelid and periocular area without foreign body, coded at the initial encounter — meaning the patient is presenting for active evaluation and/or treatment of this injury for the first time.

The periocular area includes the eyelid skin, subcutaneous tissue, lid margin, tarsus, palpebral conjunctiva, medial and lateral canthal regions, lacrimal system (canaliculi, lacrimal sac), and surrounding orbital soft tissue — any of which may be involved in a periocular laceration.

The clinical significance of an eyelid/periocular laceration is determined by several key anatomic factors:

  • Depth — superficial skin only vs. full-thickness (involving tarsus and conjunctiva) vs. penetrating (violating the orbital septum).
  • Location — involvement of the lid margin, medial canthus, lacrimal canaliculus, levator aponeurosis, or canthal tendons significantly increases surgical complexity.
  • Globe status — all eyelid lacerations must be accompanied by careful evaluation for concurrent globe injury (open globe, hyphema, lens disruption), which would shift the primary diagnosis and treatment urgency.

This code is without foreign body — if foreign body is retained (e.g., glass, wood, metal fragments), the correct code is S01.121A (laceration with foreign body of right eyelid, initial encounter).

Seventh Character — Encounter Type

ICD-10-CM injury codes require a 7th character specifying the phase of care:

7th CharacterMeaningUse When
AInitial encounterActive treatment — first visit(s) for evaluation, wound care, suture repair
DSubsequent encounterRoutine follow-up — suture removal, wound check, healing progressing normally
SSequelaResidual condition (e.g., eyelid scarring, entropion, ectropion) resulting from the original injury

S01.111A — the A suffix is required for all initial active treatment visits, including the ER, urgent care, or first office visit where repair is performed.

Anatomic Considerations

Right eyelid and periocular anatomy — structures potentially involved:

StructureClinical Significance if Lacerated
Eyelid skin onlySimple repair; cosmetically sensitive
Lid marginRequires precise anatomic layered closure; notching deformity if misaligned
TarsusStructural integrity of lid; requires deep layer repair
Palpebral conjunctivaMucosal layer; needs repair to prevent corneal abrasion from exposed suture
Levator aponeurosisSuperior eyelid only; injury causes ptosis if transected
Lacrimal canaliculus (medial)Medial lid laceration — canalicular repair with stent (Crawford tubes) required
Lacrimal sacDeep medial canthal laceration
Medial canthal tendonDeep medial trauma; canthal laxity, telecanthus if avulsed
Lateral canthal tendonLateral trauma; canthal instability
Orbital septumIf violated, orbital fat prolapse — deeper orbital injury must be excluded

Code Structure and Tree

ICD-10-CM Code Tree

  • S00-T88 Injury, poisoning and certain other consequences of external causes
    • S00-S09 Injuries to the head
      • S01 Open wound of head
        • S01.0 Open wound of scalp
        • S01.1 Open wound of eyelid and periocular area
          • S01.10 Unspecified open wound of eyelid and periocular area
          • S01.11 Laceration without foreign body of eyelid and periocular area
            • S01.111 Right eyelid and periocular area
              • S01.111A - Initial encounter
              • S01.111D - Subsequent encounter
              • S01.111S - Sequela
            • S01.112 Left eyelid and periocular area
              • S01.112A - Initial encounter
              • S01.112D - Subsequent encounter
              • S01.112S - Sequela
            • S01.119 Unspecified eyelid and periocular area (avoid)
          • S01.12 Laceration with foreign body of eyelid and periocular area
            • S01.121A Right eyelid, initial encounter
            • S01.122A Left eyelid, initial encounter
          • S01.13 Puncture wound without foreign body of eyelid
          • S01.14 Puncture wound with foreign body of eyelid
          • S01.15 Open bite of eyelid and periocular area
        • S01.2 Open wound of nose
        • S01.3 Open wound of ear
        • S01.4 Open wound of cheek and temporomandibular area
        • S01.5 Open wound of lip and oral cavity

Includes / Excludes

Includes (at S01.1 level)

  • Laceration of right eyelid skin, subcutaneous tissue, lid margin, tarsus, palpebral conjunctiva, or periocular soft tissue, without foreign body.
  • Superficial and full-thickness lacerations of the right eyelid, without retained foreign body.
  • Periocular soft tissue laceration without foreign body, right side.
  • Canalicular laceration without foreign body, right medial canthus (when clinically involving right periocular area).

Excludes1 (at S01 level — cannot be coded with S01.111A)

  • Open skull fracture — S02.- with 7th character B (if skull fracture is present with the eyelid wound, the skull fracture code with open qualifier takes priority at S02; both are coded but skull fracture uses its own open qualifier).

Excludes2 (at S01 level — may be coded alongside S01.111A when present)

  • Injury of eye and orbit — S05.- (corneal, conjunctival, globe injuries are separately coded; always examine the globe when coding S01.111A and add S05.x codes when applicable).
  • Traumatic amputation of part of head — S08.- (partial or complete eyelid avulsion uses S08.x, not S01.1x).

Code Also (per ICD-10-CM tabular instruction)

All of the following should be coded when present and documented:

  • Injury of cranial nerve — S04.- (facial nerve, oculomotor nerve injury with periocular trauma).
  • Injury of muscle and tendon of head — S09.1- (levator muscle transection, orbicularis injury).
  • Intracranial injury — S06.- (concussion, contusion, or hemorrhage concurrent with periocular trauma).
  • Wound infection — when documented post-injury (L08.89 or appropriate infection code).

External Cause Codes — Required with S01.111A

Per ICD-10-CM injury coding guidelines, always add external cause codes:

Code TypeExamples
Cause of injury (W/X/Y codes)W01.x (fall), W50.x (hit by person), X99.x (assault with sharp object), W45.x (foreign body entering eye/natural orifice)
Place of occurrenceY93.- (activity code)
Patient statusY99.8 (other external cause status)

HCC / Risk Adjustment

  • S01.111A does not map to a CMS-HCC.
  • Acute traumatic injuries do not independently generate RAF.
  • Sequela codes (S01.111S) for long-term complications (eyelid scarring causing entropion, ectropion, ptosis) also do not directly map to HCC — but functional consequences (e.g., visual field loss from cicatricial ptosis) may warrant additional clinical documentation.
  • Concurrent injuries (traumatic brain injury S06.x, orbital fracture S02.8x) may have their own HCC relevance when documented.

MS-DRG Considerations

When S01.111A is the principal diagnosis (isolated eyelid laceration):

  • MDC 02 - Diseases and Disorders of the Eye.
  • DRG 124 - Other disorders of the eye with MCC.
  • DRG 125 - Other disorders of the eye without MCC.
  • Inpatient admission for isolated eyelid laceration is uncommon — most repairs are performed in the ED, urgent care, or outpatient/ASC setting.

When concurrent injuries drive the admission:

  • MDC 01 - Nervous system (if traumatic brain injury is principal).
  • MDC 22 - Burns and traumatic injuries (if polytrauma is principal).
  • MDC 02 - Eyes (if the eyelid or orbital injury is the most resource-intensive finding).
  • S01.111A would be a secondary/contributing diagnosis.

DRG 963-965 (Other Multiple Significant Trauma): May apply in polytrauma cases.

Relationship to CPT, wRVUs, and Assistant at Surgery

wRVUs

wRVUs are assigned to CPT codes, not ICD-10-CM. For S01.111A, relevant CPT codes depend on the depth, location, and complexity of the repair:

Evaluation (ED / Urgent Care / Office)

CPTDescription
99283-99285ED E/M, moderate to high complexity (emergency setting)
99204-99205New patient office E/M (office/oculoplastics setting)
99213-99215Established patient office E/M

Eyelid Laceration Repair — CPT Selection Guide

CPTDescriptionUse When
12011Simple repair of superficial wounds, face/ears/eyelids/nose, 2.5 cm or lessSkin-only eyelid laceration, NOT involving lid margin
12013Simple repair, face, 2.6-5.0 cmSkin-only, no lid margin, longer wound
12051Intermediate repair, face, 2.5 cm or lessLayered closure, not involving lid margin
12052Intermediate repair, face, 2.6-5.0 cmLayered closure, not involving lid margin
67930Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva, direct closure; partial thicknessLid margin involved, partial thickness
67935Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva, direct closure; full thicknessLid margin involved, full thickness through all layers

Canalicular / Lacrimal System Repair

CPTDescriptionUse When
68700Plastic repair of canaliculi, bilateralBilateral canalicular laceration
68720Dacryocystorhinostomy with or without tubeLacrimal sac involvement requiring DCR
68816Probing of lacrimal system with or without irrigation, with silicone tube intubationCanalicular laceration with stent placement (Crawford tubes)

Canthal Repair

CPTDescription
21235Graft of ear cartilage, used in reconstruction — if cartilage needed
67950Canthoplasty — if canthal tendon repair is required
21280Medial canthopexy — medial canthal tendon repair/reattachment
21282Lateral canthopexy

Globe Evaluation / Concurrent Eye Injury

CPTDescription
92004Comprehensive ophthalmological exam, new patient
92014Comprehensive ophthalmological exam, established patient
92250Fundus photography
76512B-scan ultrasound (to rule out posterior globe injury when media is unclear)

CPT Selection Logic — Eyelid Repair

This is one of the most commonly miscoded areas in ophthalmology and oculoplastics:

Does the repair involve the lid margin, tarsus, or palpebral conjunctiva?

  • YES → Use CPT 67930 (partial thickness) or 67935 (full thickness) — NOT the skin repair codes.
  • NO → Use 12011-12057 (simple/intermediate repair) based on wound length and complexity.

Key rule: CPT 67930 and 67935 include all layers — do not separately bill 12011-12057 for the skin layer when 67930/67935 are used. All layers of the repair are bundled into the lid margin repair code.

Assistant at Surgery

  • 12011-12057 (simple/intermediate skin repair): Single-provider procedure. Assistant not applicable.
  • 67930/67935 (eyelid lid margin repair): Moderate complexity; assistant not typically warranted for isolated eyelid laceration.
  • Complex reconstructive cases (canthal tendon repair, canalicular stenting, orbital fracture concurrent repair): Check MPFS assistant-at-surgery indicator for specific CPT. Complex oculoplastic reconstructive procedures may allow an assistant under modifier 80 or 82 when documented.
  • Always verify MPFS assistant indicator for the specific CPT code billed.

Critical Coding Distinctions

CodeDescriptionUse When
S01.111ALaceration without FB, right eyelid, initialRight eyelid/periocular wound, no foreign body, first active treatment
S01.121ALaceration with FB, right eyelid, initialForeign body retained in right eyelid wound
S01.112ALaceration without FB, left eyelid, initialSame but left eye
S01.131APuncture wound without FB, right eyelid, initialPuncture (not laceration) of right eyelid, no FB
S01.141APuncture wound with FB, right eyelid, initialPuncture with retained FB
S01.151AOpen bite, right eyelid, initialAnimal/human bite
S05.01XAConjunctival laceration without FB, right eyeConjunctival injury without globe perforation
S05.21XAOcular laceration and rupture, right eye, initialFull globe rupture — much higher severity; change principal dx
S08.11XAComplete traumatic amputation of right ear — not eyelidFor reference — avulsion uses S08.x
S01.111DSame laceration, subsequent encounterSuture removal, wound check during healing
S01.111SSequela of right eyelid lacerationResulting scar, entropion, ectropion, ptosis from original injury

Coding Examples

Example 1 — ED Visit, Simple Right Upper Eyelid Laceration, Skin Only

Scenario 27-year-old presents to the ED after being struck by a falling object. Examination reveals a 1.8 cm superficial laceration of the right upper eyelid skin, not involving the lid margin or tarsus. Globe intact, no foreign body. Simple wound irrigation and closure with sutures performed by the ED physician.

ICD-10-CM

  • S01.111A - Laceration without foreign body of right eyelid and periocular area, initial encounter.
  • W20.8XXA - Struck by other falling object, initial encounter (external cause).
  • Y93.89 - Activity, other specified (if applicable).

CPT

  • 12011 - Simple repair of superficial wounds, face/ears/eyelids/nose, 2.5 cm or less.
  • 99283 - ED E/M, moderate complexity (separately identifiable with Modifier 25 if required by payer).

Example 2 — Oculoplastics, Full-Thickness Lid Margin Laceration Right Eye

Scenario 34-year-old referred from ED to oculoplastics after a dog bite to the face. Right lower eyelid full-thickness laceration through the lid margin, tarsus, and conjunctiva. No globe injury on exam. Levator intact. Repair performed in OR under local anesthesia — three-layer closure with lid margin sutures.

ICD-10-CM

  • S01.111A - Laceration without foreign body of right eyelid and periocular area, initial encounter.
  • W54.0XXA - Bitten by dog, initial encounter (external cause).

CPT

  • 67935 - Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; full thickness.
  • 92004 - Comprehensive ophthalmological exam, new patient (pre-operative evaluation — append Modifier 25 if billed same day as procedure).

Example 3 — Medial Canthal Laceration with Canalicular Involvement, Right Eye

Scenario 42-year-old with laceration to the medial right lower eyelid following a motor vehicle accident. Examination confirms laceration through the right lower canaliculus. Globe intact. Repair with Crawford tube stenting of right lower canaliculus and layered wound closure performed.

ICD-10-CM

  • S01.111A - Laceration without foreign body of right eyelid and periocular area, initial encounter.
  • V49.9XXA - Car occupant injured in unspecified traffic accident, initial encounter (external cause).
  • S09.10XA - Unspecified injury of muscle and tendon of head (if periocular soft tissue structures are noted as injured in documentation).

CPT

  • 68816 - Probing of lacrimal system, with silicone tube intubation (canalicular stenting — right lower canaliculus).
  • 67930 - Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; partial thickness (lid margin repair component).
  • Modifier -51 considerations — review bundling rules; 68816 and 67930 may be reportable together when both are distinctly performed; append Modifier 51 on the secondary procedure per payer instructions.

Example 4 — Follow-Up Visit, Subsequent Encounter (Code Transition)

Scenario Same dog bite patient from Example 2 returns 7 days later for suture removal. Wound healing well, no signs of infection.

ICD-10-CM

  • S01.111D - Laceration without foreign body of right eyelid and periocular area, subsequent encounter (change 7th character from A to D for routine follow-up during healing).

CPT

  • 99212-99213 - Established patient E/M, low to moderate complexity.
  • Note: Suture removal within the global period of 67935 (90-day global) — do NOT bill separately for suture removal; it is included in the global surgical package.

Example 5 — Sequela, Right Eyelid Scar Causing Ectropion

Scenario 55-year-old presents 6 months after original eyelid laceration with cicatricial ectropion of the right lower eyelid. Surgical correction planned.

ICD-10-CM

  • H02.141 - Cicatricial ectropion of right lower eyelid (the new clinical condition being treated).
  • S01.111S - Laceration without foreign body of right eyelid and periocular area, sequela (identifies the original injury as the etiology of the ectropion).

CPT

  • 67916 - Repair of ectropion; excision tarsal wedge.
  • 67917 - Repair of ectropion; extensive, including tarsal strip.

Key Coding Pearls

  • 7th character is mandatory — always specify A (initial), D (subsequent), or S (sequela). Claims will be rejected without a valid 7th character.
  • A vs. D distinction is critical — use A for every visit during active treatment of the acute injury, including the surgical repair visit and any follow-up visits for complications or active wound management. Switch to D only when the wound is in routine healing.
  • Lid margin involvement determines CPT — if the lid margin, tarsus, or palpebral conjunctiva is involved, use 67930/67935, not the skin repair codes (12011-12057). Miscoding this is one of the most frequent errors in eyelid trauma billing.
  • Always examine the globe — code S05.x if any globe injury is found; open globe (S05.21xA) would become the primary diagnosis.
  • Foreign body changes the code — no FB = S01.111A; retained FB = S01.121A. Confirm foreign body status clinically before code selection.
  • External cause codes are required — always add W/X/Y codes for mechanism of injury.
  • Canalicular lacerations in the medial right eyelid should prompt CPT 68816 consideration — this is frequently missed in documentation.
  • Suture removal is in the global period of 67930/67935 (90-day global) — do not separately bill.

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