Subluxation of C0/C1 cervical vertebrae
ICD-10 S13.110 is a billable code used to indicate a diagnosis of subluxation of c0/c1 cervical vertebrae.
Subluxation of the C0/C1 cervical vertebrae refers to a partial dislocation of the atlanto-occipital joint, which connects the base of the skull (occiput) to the first cervical vertebra (atlas). This condition can result from trauma, such as whiplash injuries, falls, or sports-related accidents. Patients may present with neck pain, restricted range of motion, headaches, and neurological symptoms if the spinal cord or nerve roots are affected. Diagnosis typically involves a thorough clinical examination, imaging studies such as X-rays or MRI to assess the alignment of the vertebrae, and to rule out associated injuries. Management may include conservative treatment like physical therapy, chiropractic adjustments, or in severe cases, surgical intervention to stabilize the joint. Complications can include chronic pain, neurological deficits, or progression to complete dislocation if not properly managed. Accurate coding is essential for appropriate treatment and reimbursement.
Documentation must include a detailed account of the injury mechanism, neurological examination findings, and imaging results.
Trauma patients presenting with neck pain after a motor vehicle accident or sports injury.
Ensure that all relevant imaging studies are documented and linked to the diagnosis.
Operative reports must detail the surgical approach, findings, and any stabilization techniques used.
Patients requiring surgical intervention for persistent symptoms or instability after conservative management.
Document the rationale for surgical intervention and any preoperative imaging findings.
Used in cases where surgical stabilization is required for subluxation.
Operative report detailing the procedure and indications.
Ensure that the surgical necessity is well-documented to support the procedure.
Subluxation refers to a partial dislocation where the joint surfaces are misaligned but still in contact, while dislocation indicates a complete separation of the joint surfaces.
