Type II occipital condyle fracture, unspecified side, 7thG

This code signifies a fracture of the occipital condyle, specifically a Type II injury according to the Anderson and Montesano classification, which involves the body of the condyle. The "unspecified side" indicates that the laterality of the fracture is not documented. This code is used when the patient is receiving follow-up care for this fracture, and the healing process is progressing slower than expected.

Apply this code for patients presenting for ongoing management of a Type II occipital condyle fracture where the healing is delayed. Documentation should clearly state "delayed healing" and specify the encounter as subsequent care for the fracture. This code is appropriate when the initial treatment has been rendered and the patient is in the healing phase.

• Ensure documentation explicitly states "delayed healing" for the occipital condyle fracture.
• Verify that the encounter is for subsequent care, not initial treatment or sequelae.
• Distinguish from nonunion (M84.38) or malunion (M84.48) if healing has completely ceased or resulted in deformity.