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ICD-10 Coding for Right Eye Injury(S05.01XA, S05.21XA)

Complete ICD-10-CM coding and documentation guide for Right Eye Injury. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Injury to Right EyeTrauma to Right Eye

Related ICD-10 Code Ranges

Complete code families applicable to Right Eye Injury

S05.0-S05.9Primary Range

Injuries to the eye and orbit

This range includes codes for various types of eye injuries, specifying laterality and encounter type.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S05.01XACorneal abrasion without foreign body, right eye, initial encounterUse for superficial corneal abrasions confirmed by slit lamp exam.
  • Fluorescein staining showing epithelial defect
S05.21XAOpen wound of eyeball with prolapse or loss of intraocular tissue, right eye, initial encounterUse for open globe injuries confirmed by clinical examination.
  • Positive Seidel test indicating aqueous leakage

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for right eye injury

Essential facts and insights about Right Eye Injury

The ICD-10 code for a right eye injury depends on the specific injury type. For instance, S05.01XA is used for a corneal abrasion without foreign body.

Primary ICD-10-CM Codes for right eye injury

Corneal abrasion without foreign body, right eye, initial encounter
Billable Code

Decision Criteria

clinical Criteria

  • Presence of corneal abrasion without foreign body

Applicable To

  • Superficial injury to cornea

Excludes

  • Corneal laceration with foreign body

Clinical Validation Requirements

  • Fluorescein staining showing epithelial defect

Code-Specific Risks

  • Misclassification as laceration

Coding Notes

  • Ensure laterality and encounter type are documented.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Struck by soccer ball

W21.02XA
Use to describe the external cause of the injury.

Injury occurring at school playground

Y92.014
Use to specify the place of occurrence.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Contusion of eyeball and orbital tissues, right eye, initial encounter

S05.11XA
Use for blunt trauma without corneal involvement.

Penetrating wound with foreign body, right eye, initial encounter

S05.51XA
Use when foreign body is present in the wound.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Right Eye Injury to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S05.01XA.

Impact

Clinical: Leads to incorrect treatment tracking., Regulatory: Non-compliance with coding standards., Financial: Potential for claim rejections.

Mitigation Strategy

Use templates that prompt for encounter type., Train staff on importance of encounter documentation.

Impact

Reimbursement: May lead to claim denials or reduced payments., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of medical records.

Mitigation Strategy

Always specify laterality and encounter type.

Impact

Coding the wrong eye can lead to audit flags.

Mitigation Strategy

Implement double-check systems for laterality.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Right Eye Injury, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Right Eye Injury

Use these documentation templates to ensure complete and accurate documentation for Right Eye Injury. These templates include all required elements for proper coding and billing.

Emergency Department Visit for Right Eye Injury

Specialty: Ophthalmology

Required Elements

  • Patient history
  • Visual acuity
  • Slit lamp examination
  • Imaging results

Example Documentation

34M struck by debris OD, immediate pain, blurred vision. VA: 20/400 OD, slit lamp: 3 mm corneal laceration OD, Seidel positive.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Eye injury, right.
Good Documentation Example
20/200 BCVA OD, 4 mm corneal laceration from 12-2 o'clock with iris incarceration, Seidel positive.
Explanation
The good example provides specific details on the injury and clinical findings.

Need help with ICD-10 coding for Right Eye Injury? Ask your questions below.

Ask about any ICD-10 CM code, or paste a medical note

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