Subluxation of C1/C2 cervical vertebrae, initial encounter

This code signifies a partial dislocation of the atlantoaxial joint, specifically between the first (atlas) and second (axis) cervical vertebrae. This subluxation involves a misalignment where the joint surfaces remain in partial contact, often causing neck pain, stiffness, and neurological symptoms.

Apply this code when documentation clearly indicates a C1/C2 subluxation in a patient presenting for initial treatment. This includes emergency department visits, initial consultations, or the first instance of care for this specific injury. Physician notes detailing the mechanism of injury, physical examination findings, and imaging reports confirming the subluxation support its use.

• Ensure the documentation specifies "subluxation" and not a complete "dislocation" (which would be a different code).
• Verify that the encounter is indeed the "initial encounter" for this specific injury; subsequent care would require a different seventh character.
• Distinguish from other cervical spine injuries, such as sprains or fractures, which have distinct ICD-10-CM codes.