Type II occipital condyle fracture, unsp side, sequela

This code signifies a Type II fracture of the occipital condyle, which is a specific type of bone break located at the base of the skull where it articulates with the top of the spine. The "sequela" designation indicates that this code is used for conditions that are residual effects or complications of an initial injury, rather than the acute injury itself. This typically involves long-term problems stemming from the fracture.

Use this code when documenting a patient presenting with a current condition or symptom that is a direct consequence of a previously sustained Type II occipital condyle fracture. Documentation should clearly state the link between the current problem and the old fracture, and specify that the fracture was not on a particular side (unspecified). Examples include chronic pain, nerve damage, or instability resulting from the healed or malunited fracture.

• Ensure documentation explicitly states the condition is a "sequela" or "late effect" of the occipital condyle fracture.
• Do not use this code for the initial, acute injury; a different code would be used for the active fracture treatment.
• Always look for laterality documentation. If the side is specified (left or right), a more specific code should be used.