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ICD-10 Guide
ICD-10 CodesS12.02

S12.02

Billable

Unstable burst fracture of first cervical vertebra

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

Code Description

ICD-10 S12.02 is a billable code used to indicate a diagnosis of unstable burst fracture of first cervical vertebra.

Key Diagnostic Point:

An unstable burst fracture of the first cervical vertebra (C1) is a severe injury characterized by the shattering of the vertebra due to high-energy trauma, often resulting from motor vehicle accidents, falls from heights, or sports injuries. This type of fracture compromises the stability of the cervical spine and can lead to significant neurological deficits due to potential spinal cord compression. Clinically, patients may present with neck pain, limited range of motion, and neurological symptoms such as weakness or sensory loss in the upper extremities. Diagnosis typically involves imaging studies, including X-rays, CT scans, and MRI, to assess the extent of the fracture and any associated spinal cord injury. Management often requires surgical intervention, such as decompression and stabilization, to prevent further neurological damage and restore spinal integrity. Post-operative care and rehabilitation are crucial for recovery, and complications may include infection, non-union of the fracture, or persistent neurological deficits.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Involves understanding of spinal anatomy and injury classification.
  • Potential for associated neurological injuries complicating coding.
  • Need for precise imaging documentation to support coding.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to document neurological assessments.
  • Misclassification of fracture stability.
  • Lack of imaging reports to support the diagnosis.

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Complete documentation of initial assessment, mechanism of injury, and neurological status.

Common Clinical Scenarios

Trauma patients presenting with neck pain after accidents or falls.

Billing Considerations

Ensure thorough documentation of any immediate interventions and imaging results.

Surgery

Documentation Requirements

Detailed operative reports including surgical approach, techniques used, and post-operative care plans.

Common Clinical Scenarios

Patients undergoing surgical stabilization of cervical spine fractures.

Billing Considerations

Document any intraoperative findings that may affect coding.

Coding Guidelines

Inclusion Criteria

Use S12.02 When
  • Follow ICD
  • CM guidelines for coding injuries, ensuring specificity in the documentation of the fracture type and any associated conditions

Exclusion Criteria

Do NOT use S12.02 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63015CPT Code

Laminectomy, cervical, for decompression of spinal cord

Clinical Scenario

Used in cases where spinal cord compression is present due to the fracture.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Ensure alignment with the diagnosis of unstable burst fracture.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of injuries like unstable burst fractures, improving data accuracy and enhancing the ability to track outcomes and complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of injuries like unstable burst fractures, improving data accuracy and enhancing the ability to track outcomes and complications.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of injuries like unstable burst fractures, improving data accuracy and enhancing the ability to track outcomes and complications.

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 S12.01 and S12.02?

S12.01 refers to a stable fracture of the first cervical vertebra, while S12.02 indicates an unstable burst fracture, which has different management and potential complications.