Posterior displaced Type II dens fracture, sequela

This code describes a long-term complication or late effect resulting from a posterior displacement of a Type II dens fracture. A Type II dens fracture involves the base of the odontoid process, which is a critical part of the C2 vertebra. "Sequela" indicates that the initial injury has healed, but there are ongoing issues directly attributable to that past fracture.

Use this code when documenting a patient presenting with a current condition or symptom that is a direct consequence of a previously sustained and healed posterior displaced Type II dens fracture. Documentation should clearly link the current problem to the old injury, often through a history of the fracture and current imaging or clinical findings demonstrating the sequela. This code is appropriate for chronic pain, instability, neurological deficits, or other persistent issues stemming from the original injury.

• Always use a sequela code (ending in "S") when the patient is seen for a complication or late effect of a healed injury, not for the initial treatment of the acute fracture.
• Do not use this code for the initial encounter or subsequent encounters for active treatment of the acute fracture; use the appropriate acute fracture code.
• Consider additional codes for specific manifestations of the sequela, such as chronic pain (e.g., G89.29) or neurological deficits, if applicable and documented.