Dislocation of C1/C2 cervical vertebrae, initial encounter

This code signifies a traumatic displacement of the first (atlas) and second (axis) cervical vertebrae from their normal anatomical alignment. This injury often results from significant force, leading to instability of the upper cervical spine. It can cause severe neurological deficits due to proximity to the brainstem and spinal cord.

Apply this code for the initial treatment of a patient presenting with a newly diagnosed C1/C2 dislocation. Documentation should clearly state the specific vertebrae involved (C1 and C2), the nature of the injury as a dislocation, and that this is the first time the patient is receiving care for this particular injury. This includes emergency department visits, initial hospital admissions, or the first outpatient encounter for this condition.

• Ensure documentation specifies "dislocation" versus "subluxation" (S13.11-).
• Always confirm the specific cervical levels involved; this code is only for C1/C2.
• Remember the 7th character "A" for initial encounter; subsequent encounters will require different 7th characters.