Subluxation of C2/C3 cervical vertebrae, sequela

This code signifies a chronic or late-effect condition resulting from a prior partial dislocation of the cervical vertebrae at the C2/C3 level. It indicates that the patient is experiencing ongoing symptoms or complications directly attributable to a past C2/C3 subluxation, even after the acute phase has resolved.

Apply this code when documentation clearly indicates a sequela (e.g., chronic pain, neurological deficits, instability) stemming from a previously diagnosed C2/C3 subluxation. The patient's current presentation must be a direct consequence of the historical subluxation, not an acute event. Look for terms like "history of C2/C3 subluxation with residual [symptom]" or "post-subluxation syndrome of C2/C3."

• Ensure the "S" seventh character is appropriate for a sequela; do not use for acute or subsequent encounters for active treatment of the initial injury.
• Always sequence this code after the primary diagnosis describing the specific sequela (e.g., chronic pain, myelopathy).
• Verify laterality and specific vertebral level (C2/C3) are explicitly documented to support this precise code.