Clinical Documentation: Connecting the Dots | Join Webinar & Earn 1 AAPC® CEURegister Now >>

Neurosurgery Coding Alert

Reader Question:

Solve ICD-10 Puzzle With Expert Advice

Question: My physician documented a type II occipital condyle fracture, right side, caused by a direct blow to the skull. This was an initial encounter for a closed fracture. Which ICD-10 code should I report for this condition?

Hawaii Subscriber

Answer: You should report S02.11CA (Type II occipital condyle fracture, right side, initial encounter for closed fracture) for this diagnosis.

Fractures of occipital condyle defined: Occipital condyle fractures occur in skull injuries caused by high-energy blunt trauma. The mechanisms of injury may include axial compression or rotation, direct blow, and lateral bending.

Providers diagnose fractures of the occipital condyle on the basis of personal history of injury, physical examination including a neurologic exam, and X–ray or CT scan. Treatment options include medication, neck stabilization with a hard cervical collar or halo vest, or surgical fixation for the fracture depending on the type and whether there is evidence of instability.