Nondisplaced Type II dens fracture, sequela

This code signifies a chronic or late-effect condition resulting from a nondisplaced fracture of the odontoid process (dens) of the second cervical vertebra (C2), specifically a Type II fracture. It indicates that the initial injury has healed, but the patient is still experiencing residual effects or complications 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, instability, nonunion, malunion, neurological deficits) directly linked to a previously sustained, nondisplaced Type II dens fracture. The medical record should explicitly mention the "sequela" or "late effect" of the prior injury.

• Always sequence this sequela code first, followed by codes for the specific residual condition(s) being treated (e.g., chronic pain, myelopathy).
• Ensure the documentation specifies "Type II" dens fracture and "nondisplaced" to support this specific code.
• Do not use acute fracture codes when coding for sequelae; acute codes are for initial encounters or active treatment of the fresh injury.