Neurosurgery Coding Alert

Question: Our surgeon repaired a dens fracture. Which diagnosis code should we report for this service?

Codify Subscriber

Answer: If you haven’t coded a dens fracture since ICD-9 was in effect, you may be surprised by the wide array of options you have for billing this injury under ICD-10.

If the surgeon did not specify the type of the fracture, you may just have to code based on whether it was displaced or nondisplaced and then report code S12.100A (Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture) or S12.101A (Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture).

When reporting Type II dens fractures, you will need to review the notes to determine the direction of the dens displacement. Depending upon the anterior or posterior displacement, you would select from code S12.110A (Anterior displaced Type II dens fracture, initial encounter for closed fracture) or S12.111A (Posterior displaced Type II dens fracture, initial encounter for closed fracture). For a nondisplaced type II fracture dens, you would report S12.112A (Nondisplaced Type II dens fracture, initial encounter for closed fracture). Typically, the surgeon will document the displacement, location, and dens type in the notes, so if that information isn’t on the superbill, the medical record can guide you.

You may turn to code S12.120A (Other displaced dens fracture, initial encounter for closed fracture) or S12.121A (Other nondisplaced dens fracture, initial encounter for closed fracture) for other dens fractures, depending upon the displaced or nondisplaced description in the clinical note that the surgeon documents.