Type III occipital condyle fracture, unspecified side, init

This code signifies a fracture of the occipital condyle, specifically a Type III injury, which involves an avulsion fracture where the alar ligament pulls off a fragment of bone. This injury is located at the base of the skull, where it articulates with the first cervical vertebra. The "unspecified side" indicates that the laterality of the fracture is not documented.

Apply this code for initial encounters when documentation confirms a Type III occipital condyle fracture, and the medical record does not specify whether the fracture is on the left or right side. This code is appropriate for closed fractures, meaning there is no open wound communicating with the fracture site. Supporting documentation would include imaging reports (e.g., CT scans) confirming the fracture type and location, along with physician notes detailing the initial assessment and treatment plan.

• Ensure documentation explicitly states "Type III" for accurate coding; other types (I, II) have distinct codes.
• Verify the encounter is "initial" for the fracture treatment; subsequent encounters require different seventh characters.
• If laterality (left or right) is specified in the documentation, use the more specific codes (S02.111A or S02.110A) instead of this "unspecified side" code.