Recurrent atlantoaxial dislocation with myelopathy

This code signifies a chronic or repeated instability of the joint between the first and second cervical vertebrae (atlas and axis), which is causing compression or damage to the spinal cord. This myelopathy can manifest with neurological symptoms such as weakness, numbness, or gait disturbance.

Apply this code when documentation clearly indicates a history of atlantoaxial dislocation that has recurred, and there is evidence of spinal cord involvement. Supporting documentation would include imaging reports (e.g., MRI showing cord compression), neurological examination findings, and a physician's explicit diagnosis of recurrent atlantoaxial dislocation with myelopathy.

• Ensure the documentation specifies "recurrent" dislocation; a single episode without recurrence would be coded differently.
• Verify the presence of myelopathy; if only instability is present without spinal cord involvement, a different code from the M43 category would be more appropriate.
• Consider sequencing this code as a primary diagnosis if it is the main reason for the encounter and treatment.