M48.41XD
ICD-10-CMFatigue fracture of vertebra, occipito-atlanto-axial region, subsequent encounter for fracture with routine healing
This code signifies a stress fracture of a vertebra located in the occipital, atlas (C1), or axis (C2) region of the cervical spine. It specifically indicates that the patient is in a subsequent phase of care, and the fracture is progressing with expected, routine healing. This is not an acute injury, but rather a chronic or overuse-related bone failure.
Apply this code for follow-up encounters where a previously diagnosed fatigue fracture of the C0-C2 vertebrae is being monitored for healing, and the healing process is proceeding without complications. Documentation should explicitly state "fatigue fracture," specify the occipito-atlanto-axial region, and indicate routine healing during a subsequent visit.
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