Type II occipital condyle fracture, left side, sequela

This code signifies a chronic or late effect of a Type II fracture of the left occipital condyle. This specific fracture involves the base of the skull where it articulates with the top of the spine, and "sequela" indicates that the patient is experiencing residual problems or complications from the original injury, which occurred at least a year prior.

Apply this code when documentation clearly indicates a patient is presenting for treatment of a long-term complication or residual effect directly attributable to a Type II occipital condyle fracture on the left side. This would include conditions like chronic pain, instability, nerve damage, or persistent neurological deficits stemming from the original injury. The medical record should explicitly state the laterality and the "sequela" nature of the current presentation.

• Ensure documentation specifies "left side" and clearly links the current condition to a past Type II occipital condyle fracture.
• Do not use this code for initial encounters or subsequent encounters for active treatment of the acute fracture; use the appropriate acute or subsequent encounter codes.
• Always code any associated chronic pain or neurological deficits separately, linking them to this sequela code as appropriate.