Posterior displaced Type II dens fracture, init for opn fx

This code signifies a fracture of the odontoid process (dens) of the C2 vertebra, specifically a Type II fracture where the posterior fragment is displaced. It indicates that the fracture is an open injury, 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 this specific injury.

Apply this code when documentation clearly states a Type II dens fracture with posterior displacement and an open wound. This is appropriate for the initial encounter when the patient is receiving active treatment for the fracture. Supporting documentation includes operative reports detailing open reduction, emergency department notes describing the open nature of the injury, and imaging reports confirming the Type II fracture and posterior displacement.

• Ensure documentation specifies "posterior displacement" as anterior displacement would require a different code.
• Verify the "open fracture" status; if closed, a different code from the S12.11- series would be appropriate.
• This "B" encounter character is only for the initial treatment phase; subsequent care would use "D" for subsequent encounter or "S" for sequela.