Other specified dorsopathies, occipito-atlanto-axial region

This code signifies a non-specific disorder affecting the upper cervical spine, specifically the joints and surrounding soft tissues of the occiput, atlas (C1), and axis (C2). It encompasses various painful or dysfunctional conditions in this region that do not fit more specific diagnostic categories.

Use this code when documentation indicates pain, stiffness, or other symptoms localized to the occipito-atlanto-axial region, and a more precise diagnosis (e.g., specific spondylosis, disc disorder, or instability) cannot be made. Supporting documentation might include physician notes describing "cervicalgia, upper cervical," "occipital neuralgia of unknown origin," or "atlantoaxial joint dysfunction, unspecified."

• Do not use this code if a more specific diagnosis for the occipito-atlanto-axial region is documented (e.g., M47.811 for spondylosis).
• Ensure the documentation clearly specifies the "occipito-atlanto-axial region" to justify its use over a more general cervical dorsopathy code.
• Consider sequencing this code after any primary pain codes (e.g., G89.xx) if pain is the predominant symptom.