Z02.5 - Encounter for examination for participation in sport

Clinical Definition

Simple open wound of the eyelid and periocular area without complication, involving only superficial tissues. This includes minor lacerations, abrasions, or cuts that do not penetrate deeper structures of the eyelid.

Documentation Requirements

• Laterality must be specified:

  • Right eyelid

  • Left eyelid

  • Upper vs. lower eyelid

• Initial vs. subsequent encounter

• Healing status (routine, delayed, etc.)

• Depth (superficial only - deeper wounds require different code)

• Absence of complications must be noted

• Mechanism of injury when known

• External cause code required

Common Synonyms

• Cut on eyelid

• Scratched eyelid

• Eyelid scrape

• Surface tear of eyelid

• Minor eye injury

Coding Conflicts

Excludes1:

• Open wounds penetrating orbital cavity (S05.-)

• Open wounds involving lacrimal structures (S05.8-)

• Deep wounds involving deeper structures

Excludes2:

• Superficial injuries of eyelid (S00.1-)

• Burns and corrosions (T26.-)

Scribing.io Automation

The AI scribe automatically detects:

• Anatomical terms ("eyelid", "periocular")

• Injury descriptors ("cut", "scratch", "abrasion")

• Laterality mentions

• Wound depth descriptions

• Absence/presence of complications
  Automatically suggests proper ICD-10 code based on documented wound characteristics.