Subluxation of C4/C5 cervical vertebrae, initial encounter

This code signifies a partial dislocation of the C4 and C5 vertebrae in the neck, meaning the joint surfaces are no longer perfectly aligned but still maintain some contact. This injury can result in pain, limited range of motion, and neurological symptoms if nerve roots are compressed.

Apply this code when documentation clearly indicates a subluxation specifically at the C4/C5 cervical level, and it represents the patient's initial presentation for this injury. Supporting documentation includes imaging reports (X-ray, MRI) confirming the subluxation and physician notes detailing the acute nature of the injury.

• Ensure the documentation specifies "subluxation" versus "dislocation" (which implies complete separation).
• Verify the specific vertebral levels (C4/C5) are explicitly stated in the diagnostic statement.
• Confirm the "A" seventh character for initial encounter is appropriate; subsequent encounters for the same injury will require different seventh characters.