Other nondisplaced dens fracture, sequela

This code signifies a long-term complication or late effect stemming from a nondisplaced fracture of the dens (odontoid process) of the C2 vertebra, where the fracture fragments remain in their anatomical position. It indicates that the initial acute injury has resolved, but the patient is now experiencing residual issues directly attributable to that past fracture.

Apply this code when a patient presents with a current condition or symptom that is a direct consequence of a previously sustained, nondisplaced dens fracture. Documentation should clearly link the current complaint (e.g., chronic pain, instability, limited range of motion, nonunion/malunion identified as a sequela) to the old injury. This code is used after the initial healing phase of the fracture.

• Requires a seventh character "S" to denote sequela, indicating a complication or late effect.
• Always sequence this code after the code(s) identifying the specific sequela (e.g., M96.0 for pseudarthrosis after fusion or M25.511 for chronic neck pain).
• Do not use for initial or subsequent encounters for the acute fracture; those require different seventh characters (A, D, G, K, P).