Nondisplaced 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, which is nondisplaced. The fracture is open, 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 nondisplaced Type II dens fracture that is open, and the patient is receiving initial active treatment for the injury. This includes scenarios such as emergency room visits, initial surgical repair, or initial casting/immobilization. Supporting documentation should include imaging reports confirming the fracture type and displacement, and physician notes detailing the open nature of the injury and the initial treatment phase.

• Ensure documentation specifies "nondisplaced" and "Type II" for accurate coding; otherwise, a different code for displaced or unspecified dens fractures may be appropriate.
• The "B" seventh character indicates an initial encounter for an open fracture; verify the encounter type and the open nature of the fracture.
• Always code any associated spinal cord injury separately if documented.