Type I occipital condyle fracture, unspecified side, init

This code signifies a fracture of the occipital condyle, specifically a Type I injury, which is an impaction fracture of the condyle without displacement into the foramen magnum. This type of fracture typically results from an axial load or lateral bending injury to the head and neck. The "unspecified side" indicates that the laterality of the fracture is not documented.

Apply this code for initial encounters when documentation clearly states a Type I occipital condyle fracture, and the fracture is closed. This code is appropriate when the medical record does not specify whether the fracture is on the left or right side. Documentation should include imaging reports (e.g., CT scan) confirming the fracture type and location.

• Ensure the documentation specifies "Type I" to differentiate from other occipital condyle fracture types (II and III).
• Verify that the encounter is the "initial encounter" for treatment of the fracture. Subsequent encounters will require a different seventh character.
• Do not use this code if the laterality (left or right) of the fracture is documented; instead, use the more specific codes for left or right side.