Type I occipital condyle fracture, right side, 7thB

This code signifies a fracture of the right occipital condyle, specifically a Type I injury, which is an avulsion fracture caused by the alar ligament. The fracture is classified as an open fracture, meaning there is a break in the skin or mucous membrane communicating with the fracture site. This code is used for the initial treatment of such an injury.

Apply this code when documentation clearly indicates a Type I occipital condyle fracture on the right side, identified as an open fracture, and the patient is receiving initial active treatment for the injury. Supporting documentation should include imaging reports confirming the fracture type and location, and physician notes detailing the open nature of the injury and the initial encounter for care.

• Ensure documentation specifies "Type I" and "right side" for accurate coding; otherwise, an unspecified or different laterality code may be more appropriate.
• The "initial encounter" designation means the patient is receiving active treatment for the fracture, not follow-up care.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter, unless another condition is explicitly stated as the primary reason for admission.