Type II occipital condyle fracture, left side, 7thK

This code signifies a specific type of fracture affecting the left occipital condyle, which is a bony prominence at the base of the skull. It indicates a Type II fracture, characterized by a fracture line extending into the foramen magnum, and specifies that the fracture has failed to heal properly (nonunion) during a follow-up visit.

Use this code for a patient presenting for ongoing management of a previously diagnosed Type II occipital condyle fracture on the left side, where imaging or clinical assessment confirms nonunion. This code is appropriate for subsequent encounters after the initial treatment, such as follow-up appointments for monitoring or planning further intervention for the nonunion. Documentation should clearly state "Type II occipital condyle fracture," "left side," and "nonunion" in the assessment and plan.

• Ensure the documentation explicitly states "Type II" and "left side" to support the specificity of this code.
• Verify that the encounter is for subsequent care of the fracture, not the initial treatment, and that nonunion is clearly documented.
• Distinguish from malunion, which implies healing in an abnormal position, whereas nonunion indicates a complete failure to heal.