M48.41XG
ICD-10-CMFatigue fracture of vertebra, occipito-atlanto-axial region, subsequent encounter for fracture with delayed healing
This code signifies a stress fracture of a vertebra in the upper cervical spine (occiput, C1, or C2) that is not healing as expected. It indicates that the patient is receiving ongoing care for this specific fracture after the initial treatment phase. The "G" seventh character specifies delayed healing.
Apply this code when a patient presents for follow-up care of a previously diagnosed fatigue fracture in the occipito-atlanto-axial region, and the physician documents that the fracture is experiencing delayed union or non-union. Supporting documentation would include imaging reports showing incomplete healing and physician notes detailing the ongoing management of the fracture.
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