2025 ICD-10-CM code S02.11AA
Type I occipital condyle fracture, right side, initial encounter for closed fracture.
Medical necessity is established by the presence of a fracture requiring evaluation, management, and treatment. The type of treatment (conservative vs. surgical) will depend on the specifics of the fracture, such as displacement and stability, and the patient's clinical presentation.
In simple words: A Type I fracture of the right occipital condyle, the area where the skull connects to the neck, caused by compression (crushing). This code is used for the first visit for a closed fracture (one that doesn't break the skin).
A type I occipital condyle fracture, right side, is a compression fracture of the portion of the occiput located at the juncture of the neck and skull. This code applies to the initial encounter for a closed fracture of the occipital condyle.
Example 1: A patient fell and hit their head, resulting in a closed, type I fracture of the right occipital condyle. This is their first visit for this injury., A patient was involved in a motor vehicle accident and sustained a closed, type I fracture of the right occipital condyle. They are being seen in the emergency room for the first time for this injury., A patient experienced a sports-related injury leading to a closed, type I fracture of the right occipital condyle. This is the initial encounter for this injury.
Documentation should include details of the injury mechanism, physical examination findings, and imaging results (X-ray or CT scan) confirming the diagnosis of a closed, type I fracture of the right occipital condyle. Neurological assessment findings should also be documented.
** For subsequent encounters for this fracture, use codes S02.11XD, S02.11XG, S02.11XK or S02.11XS for subsequent closed fracture care, or S02.11YA, S02.11YB, S02.11YD, S02.11YG, S02.11YK or S02.11YS for subsequent open fracture care.