ICD 10 CM S04.011D | Description & Clinical Information

ICD 10 S04.011D describes a specific medical condition that involves damage or injury to the optic nerve located in the right eye, which is one of the two cranial nerves responsible for transmitting visual information from the retina to the brain, and this code is used to indicate a subsequent encounter for the same injury.

Official Description Of S04.011D

The ICD 10 CM book defines ICD 10 code S04.011D as:

Injury of optic nerve, right eye, subsequent encounter
Parent Code Notes: S04.0

Use additional code to identify any visual field defect or blindness (H53.4-, H54.-)

Parent Code Notes: S04

Code first any associated intracranial injury (S06.-)

Code also: any associated:
open wound of head (S01.-)
skull fracture (S02.-)

When To Use S04.011D

The diagnosis describes by the code ICD 10 CM S04.011D is related to a specific type of injury that may occur in the optic nerve of the right eye. This injury can result in a range of symptoms that can vary in severity, including partial or complete loss of vision, blind spots, distorted vision, reduced ability to identify different colors, or color blindness, and or pain while moving the eyes.

When a healthcare provider suspects that a patient has suffered an injury to the optic nerve in the right eye, they typically conduct a thorough medical evaluation to determine the underlying cause of the injury. This evaluation includes a detailed patient history, which includes information about the mechanism of injury and a discussion of the patient’s signs and symptoms. The examination also includes several tests to assess the patient’s vision, eye pressure, and other factors. These tests can include a visual acuity test, pupillary reflex, ophthalmoscopy, and more.

Imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) can also help identify the extent and severity of the injury. These imaging techniques provide detailed information about the optic nerve and surrounding structures and can assist in the development of an effective treatment plan.

Once the injury is diagnosed, a healthcare provider can begin developing an individualized treatment plan for the patient. Treatment options for optic nerve injuries may include the use of corticosteroids, which can help reduce inflammation and promote healing in the affected area. In some cases, surgical optic nerve decompression may also be performed to relieve pressure on the optic nerve.

It is essential to note that the prognosis for an optic nerve injury can vary widely based on the extent and timing of the injury and the type of treatment that is provided. Early and accurate diagnosis, along with prompt and effective treatment, can help improve the patient’s chances of a favorable outcome.

In conclusion, the ICD 10 CM S04.011D code represents a specific diagnosis related to an injury of the optic nerve in the right eye. A thorough medical evaluation, including a patient history, eye examinations, and imaging techniques, can help diagnose the injury and determine the best course of treatment. While the prognosis for optic nerve injuries can vary widely, early diagnosis and treatment can improve the patient’s chances of a successful recovery.

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