Spinal enthesopathy, occipito-atlanto-axial region

This code signifies inflammation and degeneration at the entheses (sites where tendons, ligaments, or joint capsules attach to bone) within the occipito-atlanto-axial region of the spine. It indicates a painful condition affecting the upper cervical spine, specifically the joints connecting the skull to the first two vertebrae.

Use this code when documentation specifies enthesopathy affecting the occiput, atlas (C1), or axis (C2). This typically presents with localized pain, stiffness, and tenderness in the upper neck, often exacerbated by movement. Supporting documentation should clearly identify the anatomical region and the nature of the condition as enthesopathy.

• Ensure documentation explicitly states "enthesopathy" and specifies the occipito-atlanto-axial region; avoid using for general neck pain.
• Do not confuse with other cervical spondylopathies or localized inflammatory conditions without specific entheseal involvement.
• Consider sequencing this code as a primary diagnosis when it is the main reason for the encounter, or as a secondary diagnosis if it's a co-morbidity.