Fusion of spine, occipito-atlanto-axial region
ICD-10 M43.21 is a billable code used to indicate a diagnosis of fusion of spine, occipito-atlanto-axial region.
The occipito-atlanto-axial region refers to the uppermost part of the cervical spine, which includes the occipital bone at the base of the skull, the atlas (C1), and the axis (C2). Fusion of this region is often indicated in cases of instability, congenital deformities, or degenerative diseases that compromise the structural integrity of the spine. Conditions such as atlantoaxial instability, Chiari malformation, or severe degenerative disc disease may necessitate surgical intervention to stabilize the spine and prevent neurological deficits. The procedure involves the surgical fusion of the vertebrae using bone grafts or implants, which can lead to improved stability and reduced pain. Post-operative care and rehabilitation are crucial for recovery, and monitoring for complications such as infection or non-union of the fusion site is essential. This code is particularly relevant in the context of spinal deformities, including scoliosis, kyphosis, and lordosis, where surgical intervention may be required to correct or stabilize the spine.
Detailed operative reports, imaging studies, and pre-operative evaluations.
Surgical intervention for congenital deformities, trauma, or degenerative diseases affecting the upper cervical spine.
Ensure that the documentation supports the need for fusion and addresses any associated neurological symptoms.
Comprehensive neurological assessments, imaging results, and detailed operative notes.
Management of Chiari malformation or atlantoaxial instability requiring surgical intervention.
Focus on documenting neurological evaluations and the rationale for surgical intervention.
Used in conjunction with M43.21 for surgical fusion of the occipito-atlanto-axial region.
Operative report detailing the procedure, indications, and any complications.
Orthopedic and neurosurgical specialties should ensure alignment of procedure codes with diagnosis.
M43.21 is used for conditions that require surgical fusion of the occipito-atlanto-axial region, such as atlantoaxial instability, Chiari malformation, or severe degenerative diseases affecting stability.
