Fatigue fracture of vertebra, occipt-atlan-ax region, sqla

This code signifies a stress fracture of a vertebra in the upper cervical spine (occiput, atlas, or axis) that occurred as a result of repetitive stress or overuse, and is now being reported as a long-term effect or complication of a previously healed fracture. It indicates that the current fatigue fracture is a sequela, meaning a condition following and resulting from an earlier disease or injury.

Apply this code when documentation clearly states a fatigue fracture of the C0-C2 vertebrae, and explicitly links it as a sequela of a prior fracture in the same region. This typically involves chronic pain or instability developing years after an initial fracture has healed. Supporting documentation would include imaging reports confirming the fatigue fracture and a history detailing the previous fracture and its resolution.

• Ensure documentation specifies "fatigue fracture" and not an acute traumatic fracture.
• The "S" seventh character indicates sequela; do not use for active or initial encounters for the fatigue fracture.
• Always sequence this code after the primary reason for the encounter, if applicable, and ensure the medical record supports the sequela relationship.