Type II occipital condyle fracture, unspecified side, init

This code signifies a fracture of the occipital condyle, specifically a Type II fracture according to the Anderson and Montesano classification, which involves the base of the condyle and extends into the foramen magnum. This injury is typically stable but can be associated with craniocervical junction instability.

Apply this code when documentation explicitly states a Type II occipital condyle fracture, without specifying laterality, in a patient presenting for initial treatment of a closed injury. This is appropriate for acute presentations following trauma where the skin remains intact over the fracture site.

• Ensure documentation specifies "Type II" to differentiate from Type I (impaction) or Type III (avulsion) fractures.
• Confirm the encounter is for the initial treatment of the fracture; subsequent encounters will require different seventh characters.
• Verify the fracture is "closed"; open fractures have distinct coding.