Subluxation of C6/C7 cervical vertebrae, initial encounter

This code signifies a partial dislocation of the C6 and C7 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 for a patient presenting with a newly diagnosed C6/C7 subluxation, or when receiving active treatment for a recent injury. Documentation should clearly state "subluxation" at the C6/C7 level and indicate this is the initial encounter for this specific injury.

• Ensure documentation specifies "subluxation" versus "dislocation" (which would be S13.15xA or S13.16xA).
• Verify the specific vertebral levels (C6/C7) are explicitly stated in the physician's notes.
• The "A" seventh character indicates an initial encounter for active treatment; use subsequent characters for follow-up care.