Dislocation of T4/T5 thoracic vertebra, initial encounter

This diagnosis code signifies a complete or partial displacement of the fourth thoracic vertebra (T4) from its normal articulation with the fifth thoracic vertebra (T5). This injury can result in significant pain, neurological deficits, and spinal instability.

Apply this code when documentation clearly indicates a dislocation between the T4 and T5 vertebrae, such as from a traumatic event like a fall, motor vehicle accident, or direct impact. This specific code is for the initial encounter for this injury, meaning the patient is receiving active treatment for the dislocation.

• Ensure the documentation specifies T4/T5 involvement; do not use for other thoracic levels.
• Verify that the encounter is indeed the initial treatment for the dislocation, not a follow-up or sequela.
• Look for associated neurological deficits (e.g., myelopathy, radiculopathy) that may require additional coding.