Unspecified nondisplaced fracture of second cervical vertebra
ICD-10 S12.101 is a billable code used to indicate a diagnosis of unspecified nondisplaced fracture of second cervical vertebra.
The S12.101 code refers to an unspecified nondisplaced fracture of the second cervical vertebra (C2), commonly known as the axis. This type of fracture typically occurs due to trauma, such as falls, motor vehicle accidents, or sports injuries. Nondisplaced fractures indicate that the bone has cracked but remains in its normal anatomical position, which may lead to less severe symptoms compared to displaced fractures. Clinical presentation often includes neck pain, limited range of motion, and potential neurological symptoms if the spinal cord is affected. Diagnosis is primarily through imaging studies, such as X-rays or MRI, to confirm the fracture and assess any associated injuries. Management usually involves conservative treatment, including immobilization with a cervical collar and pain management, although surgical intervention may be necessary in cases of instability or neurological compromise. Complications can include chronic pain, reduced mobility, or, in severe cases, spinal cord injury. Accurate coding requires thorough documentation of the mechanism of injury, clinical findings, and treatment provided.
Documentation must include the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting after falls, sports injuries, or motor vehicle accidents.
Ensure that all neurological assessments are documented, especially if there are signs of spinal cord involvement.
Operative reports must detail the surgical approach, findings, and any fixation methods used.
Surgical intervention for unstable fractures or those with neurological deficits.
Document any pre-existing conditions that may affect surgical outcomes.
Used when surgical intervention is required for stabilization.
Operative report detailing the procedure and indications.
Ensure that the surgical necessity is well documented.
A displaced fracture involves a break where the bone fragments are separated, while a nondisplaced fracture means the bone cracks but remains aligned.
