ICD-10-CM Billable Code

S02.11A

Type I occipital condyle fracture, right side

Clinical Classification Guidelines

Medical Intelligence & Overview

A Type I occipital condyle fracture involving the right side is a specific type of skull injury affecting the bony protrusions at the base of the skull called the occipital condyles. These structures connect the skull to the cervical spine and play a crucial role in head movement. This fracture is classified as a stable injury, usually caused by trauma such as blunt force, and often requires careful medical evaluation to determine the extent of injury and appropriate management.

Causes & Symptoms

Clinical Causes: Motor vehicle accidents Falls from heights Sports injuries Direct blows to the back of the head Trauma from accidents or violent impacts

Key Symptoms: Neck pain or stiffness Headache located at the back of the head Limited range of motion in the neck Tenderness upon palpation behind the ears or at the base of the skull Possible nerve-related symptoms such as tingling or weakness if nerve roots are affected

Diagnostic & Treatment

Diagnosis Path: Diagnosing a Type I occipital condyle fracture involves a combination of clinical examination and imaging studies. Healthcare providers may perform a detailed physical assessment to evaluate neck stability and neurological function. Imaging techniques such as computed tomography (CT) scans are most effective in visualizing the fracture and determining its stability, particularly because they provide detailed cross-sectional images of bone structures. Magnetic resonance imaging (MRI) may also be employed if there is suspicion of associated soft tissue or nerve injuries.

Treatment Protocols: Management of a Type I occipital condyle fracture primarily aims to ensure stability and facilitate healing. Treatment strategies include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S02.11A a billable ICD-10 code?
Yes, S02.11A is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S02.11A?
Clinical documentation must specify the nature of Type I occipital condyle fracture, right side and any associated comorbidities for accurate reporting.

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