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S02.31XA

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S02.31XA - Fracture of Orbital Floor, Right Side, Initial Encounter for Closed Fracture

Short Description

S02.31XA: Use for a right orbital floor (“blowout”) fracture in the active treatment phase when the fracture is closed (bone does NOT penetrate skin) and the encounter is coded as initial (7th character A) for that episode of care.

Full Description & Clinical Context

S02.31XA describes a closed fracture of the orbital floor on the right side of the skull during an initial encounter while the patient is receiving active treatment (ED care, initial evaluation, surgical repair, etc.).

  • Orbital floor = the thin bone forming the bottom of the eye socket; commonly fractured in “blowout” injuries from blunt facial trauma (fist, ball, MVC, falls).
  • Right side = laterality is specified; this code is only for right orbital floor fractures.
  • Closed fracture = no open wound communicating with the fracture site.

Typical clinical features: periorbital swelling and ecchymosis, diplopia, infraorbital nerve hypoesthesia, enophthalmos, restricted eye movement (muscle entrapment), and facial pain after trauma.

Code Structure Breakdown

S02.31XA = S 02 . 31 X A

  • S = Injury/trauma chapter (S00-T88).
  • S02 = Fracture of skull and facial bones.
  • S02.3 = Fracture of orbital floor.
  • S02.31 = Fracture of orbital floor, right side.
  • X = Placeholder (so the 7th character can be placed in position 7).
  • A = Initial encounter for closed fracture (active treatment).

Key ICD-10 fracture guidelines:

  • 7th char A = initial encounter (active treatment: evaluation, surgery, casting, etc.).
  • “Initial” is about treatment phase, NOT necessarily the first calendar visit; multiple providers can all use A if they are still providing active treatment.

Official Descriptor & Coding Notes

  • Full descriptor: “Fracture of orbital floor, right side, initial encounter for closed fracture.”
  • Billable/specific: Yes - valid for HIPAA claims for current FY.
  • Chronic condition indicator: Not chronic - acute traumatic injury.

Parent code notes (S02.3 - Fracture of orbital floor):

  • Excludes 1:
    • Orbit NOS → S02.85
  • Excludes 2:
    • Lateral orbital wall → S02.84-
    • Medial orbital wall → S02.83-
    • Orbital roof → S02.1-
  • Code also: any associated intracranial injury (S06.-) when present.

7th Characters & Variants for S02.31 (Right Orbital Floor)

All right-sided orbital floor fractures share S02.31 and differ only in the 7th character and open/closed status:

CodeMeaning
S02.31XARight orbital floor fx, initial encounter, closed fracture
S02.31XBRight orbital floor fx, initial encounter, open fracture
S02.31XDRight orbital floor fx, subsequent encounter, routine healing
S02.31XGRight orbital floor fx, subsequent encounter, delayed healing
S02.31XKRight orbital floor fx, subsequent encounter, nonunion
S02.31XSRight orbital floor fx, sequela (residuals after injury healed)

Key distinctions:

  • Initial (A/B): while fracture is under active treatment.
  • Subsequent (D/G/K): healing phase - follow-up care, routine or with complications (delayed healing, nonunion).
  • Sequela (S): late effects - diplopia, chronic pain, deformity, etc., due to prior fracture.

Laterality Family - All Orbital Floor Fracture Codes

Base CodeDescriptionSide / Lateral Info
S02.30Fracture of orbital floor, unspecified sideLaterality not documented
S02.31Fracture of orbital floor, right sideRight orbit
S02.32Fracture of orbital floor, left sideLeft orbit

Each of these expands with 7th characters (A/B/D/G/K/S) and X placeholder for encounter details.

Best practice: avoid S02.30; code S02.31 or S02.32 whenever laterality is documented.

HCC Information

  • S02.31XA does NOT map to a CMS-HCC - traumatic fractures generally do not have direct HCC weight in risk models.
  • However, associated conditions might map to HCCs (e.g., coma, certain neurologic sequelae), but the fracture itself does not.

Use S02.31XA primarily for acute trauma severity, DRG grouping, and medical necessity for imaging and surgical repair, not for risk-score capture.

RVU / wRVU Information

  • ICD-10-CM codes (including S02.31XA) do NOT carry RVUs/wRVUs. RVUs are attached to CPT/HCPCS codes.
  • S02.31XA influences DRG assignment (if inpatient) and supports medical necessity for associated procedures/E&M, but does not itself have a wRVU.

Typical impact:

  • Justifies advanced imaging (CT orbit/face), operative repair (ORIF, reconstruction), anesthesia, and high-complexity E/M levels.

Common Associated ICD-10-CM Codes

Frequently paired with S02.31XA in facial/orbital trauma workups:

Other facial fractures:

  • S02.2XXA - Fracture of nasal bones, initial.
  • S02.4XXA - Fracture of malar/zygoma.
  • S02.40x- / S02.4x- - Check exact laterality for zygomatic complex.

Eye/orbit injuries:

  • S05.11XA - Contusion of right eyeball and orbital tissues, initial.
  • S05.31XA - Ocular laceration/other specific injuries (as documented).

Intracranial injury (if present):

  • S06.0X0A - Concussion without loss of consciousness, initial.
  • S06.5X0A - Traumatic subdural hemorrhage without loss of consciousness, initial.

External cause codes (E-codes):

  • W01.0XXA - Fall on same level from slipping/tripping (example).
  • Y04.0XXA - Assault by bodily force (punch).
  • V43.52XA - Car occupant in collision (example).

External cause codes are not required for payment in many settings, but are recommended to describe the mechanism of injury per official guidelines.

Common CPT Procedure Codes (Examples)

These are example CPT codes that frequently appear with orbital floor fractures; always match to operative note and facility standards.

Imaging:

  • 70480 - CT orbit, without contrast.
  • 70481 - CT orbit, with contrast.
  • 70482 - CT orbit, without and with contrast.

Operative repair (ENT/Oculoplastics/Plastics - examples):

  • 21390 - Open treatment of nasomaxillary complex fracture (LeFort I or similar) - often used with midface/orbital involvement.
  • 21395 - Open treatment of complex facial fracture, with or without bone graft.
  • 21406 / 21407 / 21408 - Open treatment of orbital fracture(s), including floor/medial wall, with or without implants (check exact crosswalk at your facility).
  • 21210 - Graft, bone; nasal, maxillary, or malar area (if bone graft used for reconstruction).

Anesthesia & E/M:

  • 00140 - Anesthesia for eye procedures (including orbit) - per anesthesia provider.
  • 9928x / 9920x - ED or office E/M for initial evaluation.
  • 9922x / 9923x - Inpatient initial/subsequent hospital care for facial trauma.

(Numbers here illustrate patterns; your facility might have specific favorite codes or templates—always confirm against current CPT manual.)

Encounter Status & 7th Character Pearls

Initial (A/B): Use A (closed) or B (open) when:

  • Patient is receiving active treatment for the fracture:
    • ED evaluation, imaging, splinting.
    • Surgical repair/ORIF.
    • Acute management of complications (e.g., muscle entrapment surgery).

Subsequent (D/G/K):
Use for follow-up fracture care after active treatment complete:

  • D - routine healing.
  • G - delayed healing.
  • K - nonunion.

Sequela (S):
Used when treating late effects of the fracture:

  • Persistent diplopia, enophthalmos, chronic neuropathic pain due to infraorbital nerve damage, etc.
  • Code the residual condition first, then fracture code with -XS.

Documentation Tips for S02.31XA

To support S02.31XA, ideal documentation should clearly state:

  • Anatomical site: “Right orbital floor fracture,” “right orbital blowout fracture.”
  • Laterality: specifically “right” (not just “orbital fracture”).
  • Open vs closed: “Closed orbital floor fracture” (no skin breach) or explicitly “no open wound.”
  • Type of encounter: ED visit/initial trauma evaluation/operative repair → active treatment.
  • Mechanism of injury: punch, ball, MVC, fall, etc. (for external cause codes).
  • Associated injuries: globe injury, extraocular muscle entrapment, nerve injury, intracranial trauma.

Red flags / query opportunities:

  • “Orbital fracture” only - clarify which wall (roof, floor, medial, lateral).
  • No laterality - query for right vs left vs unspecified.
  • No open/closed status - default is usually closed, but confirm if questionable.
  • Follow-up visit using A when treatment is clearly in healing phase - consider D/G/K instead once active treatment ends per guidelines.

Quick Reference Card

ICD-10-CM S02.31XA - Fracture of Orbital Floor, Right Side,
Initial Encounter for Closed Fracture
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
USE WHEN:
-  Right orbital floor (“blowout”) fracture
-  Closed fracture (no open wound)
-  Patient is in ACTIVE TREATMENT phase
  - ED evaluation, imaging, surgery, acute management
-  Encounter is for initial active treatment (even if not first visit)

DO NOT USE WHEN:
-  Side is left (use S02.32x-)
-  Side is unspecified (S02.30x- - try to avoid; query for laterality)
-  It is a FOLLOW-UP visit after fracture has entered healing phase
  - use S02.31XD/XG/XK for subsequent encounters instead
-  You are coding late effects (diplopia, deformity) long after fracture healed
  - use S02.31XS as sequela code

KEY POINTS:
-  7th char “A” = initial encounter for closed fracture
-  “X” is a placeholder to allow the 7th character
-  Code also any associated intracranial injury (S06.-)
-  Add external cause codes (fall, assault, MVC) if required/recommended

Last Updated: February 9, 2026
For coding reference only - always verify against the current ICD-10-CM, CPT, payer policies, and trauma documentation guidelines.
Key concept: S02.31XA captures a right, closed orbital floor fracture during active treatment; use other 7th characters for subsequent care and sequelae

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