Type III occipital condyle fracture, unsp side, sequela

This code signifies the long-term effects or complications arising from a Type III occipital condyle fracture, where the side of the fracture (left or right) was not specified in the original injury documentation. A Type III fracture involves an avulsion injury where the alar ligament is pulled away from the condyle, often associated with craniocervical dissociation. The "sequela" aspect indicates that the patient is now presenting for treatment of a residual condition directly attributable to this past injury.

Apply this code when a patient is being treated for a chronic condition, disability, or complication that is a direct result of a previously sustained Type III occipital condyle fracture of an unspecified side. Documentation should clearly link the current condition to the past fracture and specify that the original injury occurred on an unknown side. Examples include persistent pain, neurological deficits, or instability stemming from the old fracture.

• Always sequence the sequela code first, followed by codes for the specific residual condition being treated.
• Ensure documentation explicitly states "sequela" or clearly indicates a chronic condition resulting from a past injury.
• Avoid using this code for acute or subacute fracture care; it is strictly for long-term effects.