Type II occipital condyle fracture, right side, sequela

This code signifies a chronic or late effect of a fracture involving the right occipital condyle, specifically a Type II fracture. This type of fracture typically involves the base of the condyle and is often stable. The "sequela" designation indicates that the patient is presenting for treatment of a residual condition or complication directly resulting from the original injury, rather than the acute injury itself.

Apply this code when documentation clearly indicates a patient is being treated for a long-term consequence or complication of a previously sustained Type II occipital condyle fracture on the right side. This could include chronic pain, neurological deficits, or instability directly attributable to the old fracture. Documentation should specify the laterality (right) and the Type II classification of the original fracture.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) being treated.
• Ensure documentation explicitly states "sequela," "late effect," or describes a chronic condition resulting from the original fracture.
• Do not use this code for acute or initial treatment of the fracture; refer to the acute fracture codes for that scenario.