S05.31XA Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter

ICD10CM code

#### Name of the Condition
- Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter
- Commonly referred to as a superficial eye injury or minor eye laceration.

#### Summary
- This condition involves a cut or tear in the right eye that does not result in the expulsion or loss of intraocular tissue. It impacts the eye's outer structures and is addressed in the initial encounter with medical professionals.

#### Causes
- Caused by trauma to the eye from sharp objects, accidents during sports, falls, or any direct impact that can cut the eye's surface.

#### Risk Factors
- Higher risk in individuals involved in sports or physical activities, those working with sharp tools, or in hazardous environments without protective eyewear.

#### Symptoms
- Symptoms may include eye pain, redness, tearing, blurred vision, and a visible cut on the surface of the eye.

#### Diagnosis
- Diagnosed through a physical examination by an eye care professional. This may involve using a slit lamp to inspect the eye more closely and fluorescein dye to highlight abrasions.

#### Treatment Options
- Treatment usually includes cleaning the wound to prevent infection, prescribing antibiotic eye drops or ointments, and using an eye patch to protect the eye and promote healing.
- Severe cases may require further intervention by an ophthalmologist.

#### Prognosis and Follow-Up
- With prompt and appropriate treatment, most patients recover fully without vision loss. Follow-up visits ensure the eye is healing properly and to monitor for any signs of infection or complications.

#### Complications
- Potential complications can include infection, increased intraocular pressure, or damage to deeper structures if the injury is not adequately treated.

#### Lifestyle & Prevention
- Wearing protective eyewear during high-risk activities is essential. Awareness of surroundings and taking precautions in environments where eye injuries may occur can help prevent lacerations.

#### When to Seek Professional Help
- Seek medical attention immediately if you experience severe eye pain, bleeding, vision changes, or any trauma to the eye.

#### Additional Resources
- American Academy of Ophthalmology (aao.org)
- National Eye Institute (nei.nih.gov)

#### Tips for Medical Coders
- Ensure accurate documentation of the encounter type, eye affected, and specific nature of the injury.
- Avoid common errors such as incorrect laterality coding, especially when distinguishing between initial and subsequent encounters.

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