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ICD-10 Guide
ICD-10 CodesS12.331

S12.331

Billable

Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S12.331 is a billable code used to indicate a diagnosis of unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra.

Key Diagnostic Point:

S12.331 refers to a specific type of spinal injury characterized by a nondisplaced spondylolisthesis at the fourth cervical vertebra (C4). This condition occurs when one vertebra slips forward over another due to trauma, but without any displacement of the vertebral body. Common mechanisms of injury include falls, motor vehicle accidents, or sports-related injuries. Patients may present with neck pain, limited range of motion, and neurological symptoms depending on the severity of the injury. Diagnosis typically involves a thorough clinical evaluation, imaging studies such as X-rays or MRI to assess the alignment and integrity of the cervical spine. Management may include conservative treatment like physical therapy and pain management, or surgical intervention if neurological compromise is present. Complications can include chronic pain, instability of the cervical spine, or potential for further neurological injury if not properly managed.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of spinal anatomy and injury mechanisms
  • Differentiation from other cervical spine injuries
  • Need for precise documentation of trauma history
  • Potential for associated neurological symptoms

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the level of the cervical spine affected
  • Misclassification of the type of spondylolisthesis
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Complete trauma assessment, including mechanism of injury and neurological evaluation.

Common Clinical Scenarios

Patients presenting with neck pain after a fall or motor vehicle accident.

Billing Considerations

Ensure thorough documentation of all findings and imaging results to support coding.

Surgery

Documentation Requirements

Detailed operative notes and preoperative assessments.

Common Clinical Scenarios

Surgical intervention for cervical instability or decompression due to spondylolisthesis.

Billing Considerations

Document any intraoperative findings that may affect coding and billing.

Coding Guidelines

Inclusion Criteria

Use S12.331 When
  • Follow ICD
  • CM guidelines for coding injuries, ensuring accurate documentation of the injury's nature, location, and cause
  • Use additional codes for any associated conditions or complications

Exclusion Criteria

Do NOT use S12.331 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22551CPT Code

Anterior cervical discectomy and fusion

Clinical Scenario

Used in cases where surgical intervention is necessary due to instability or neurological compromise.

Documentation Requirements

Operative report detailing the procedure and indications for surgery.

Specialty Considerations

Ensure that the surgical necessity is well documented to support the procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of spinal injuries, improving the accuracy of diagnoses and treatment tracking. S12.331 provides specificity that was not available in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of spinal injuries, improving the accuracy of diagnoses and treatment tracking. S12.331 provides specificity that was not available in ICD-9.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of spinal injuries, improving the accuracy of diagnoses and treatment tracking. S12.331 provides specificity that was not available in ICD-9.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between displaced and nondisplaced spondylolisthesis?

Displaced spondylolisthesis involves a vertebra that has moved out of its normal position, while nondisplaced means the vertebra remains in alignment despite the injury.