Subluxation of C4/C5 cervical vertebrae, subs encntr

This code indicates a partial dislocation or misalignment of the C4 and C5 vertebrae in the neck. It specifically applies when the patient is receiving follow-up care for this injury, such as during rehabilitation, subsequent office visits, or after initial treatment. The spinal cord and nerve roots may or may not be affected.

Apply this code for patients presenting for ongoing management of a previously diagnosed C4/C5 subluxation. This includes physical therapy sessions, follow-up appointments to monitor healing, or adjustments to treatment plans after the initial injury has been addressed. Do not use for the initial encounter for the injury.

• Requires a seventh character "D" for subsequent encounter, indicating active treatment or follow-up care.
• Ensure documentation clearly specifies the C4/C5 level and confirms it is a subluxation, not a fracture or complete dislocation.
• Pair with external cause codes (V, W, X, Y categories) if the cause of the injury is known and documented.