Stable burst fracture of first cervical vertebra, sequela

This code signifies a long-term complication or late effect resulting from a stable burst fracture of the C1 vertebra (atlas). It indicates that the initial traumatic injury has healed, but the patient is still experiencing residual issues directly attributable to that past fracture.

Apply this code when documentation clearly states a patient is presenting for treatment of a sequela (e.g., chronic pain, neurological deficit, instability) directly related to a previously sustained and now stable burst fracture of the first cervical vertebra. The "S" in the 7th character indicates sequela, meaning the initial injury occurred in the past and the patient is now being treated for its residual effects.

• Ensure documentation explicitly links the current condition to the past C1 burst fracture.
• Do not use for initial encounter or subsequent encounter for active treatment of the fracture itself.
• Always sequence this code after the primary diagnosis describing the specific sequela being treated (e.g., chronic cervical pain, cervical radiculopathy).