ICD-10-CM Billable Code

S04.1

Injury of oculomotor nerve

Clinical Classification Guidelines

Inclusion Terms

  • Injury of 3rd cranial nerve

Medical Intelligence & Overview

An injury to the oculomotor nerve, also known as the 3rd cranial nerve, affects eye movement and pupil function. This nerve controls most of the eye's movements, constriction of the pupil, and maintains an open eyelid. Damage to this nerve can result in vision problems and abnormal eye positioning, impacting daily activities and quality of life.

Causes & Symptoms

Clinical Causes: Trauma or blow to the head or face Brain aneurysm or vascular disorders Brain tumors affecting the nerve pathway Inflammatory conditions such as multiple sclerosis Infections involving the brain or nerve tissue Diabetic neuropathy leading to nerve damage Surgical injury during brain or eye procedures

Key Symptoms: Drooping eyelid (ptosis) Double vision (diplopia) Eye turned outward or downward (lateral or downward deviation) Difficulty moving the eye in certain directions Dilated pupil that does not constrict properly Impaired focus or blurred vision Possible headache or eye pain in some cases

Diagnostic & Treatment

Diagnosis Path: Diagnosis involves a comprehensive eye examination and neurological assessment. Healthcare providers may perform:

Treatment Protocols: Management depends on the underlying cause and the severity of the nerve injury. Common approaches include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S04.1 a billable ICD-10 code?
Yes, S04.1 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S04.1?
Clinical documentation must specify the nature of Injury of oculomotor nerve and any associated comorbidities for accurate reporting.

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