Neurosurgery Coding Alert

Question: My surgeon documented an initial encounter for an anterior displaced type II dens open fracture. How should I report this diagnosis, and what exactly is a dens fracture?

Minnesota Subscriber

Answer: You should report S12.110B (Anterior displaced Type II dens fracture, initial encounter for open fracture) for this diagnosis.

Don’t miss: When reporting type II dens fractures, you will need your surgeon to specifically record the direction of displacement of the dens. You can choose from anterior, posterior, or displaced.

For example, if the neurosurgeon documented an initial encounter for an anterior displaced type II dens open fracture, then you would report S12.110B (Anterior displaced Type II dens fracture, initial encounter for open fracture).

For a nondisplaced type II fracture dens, you would report code S12.112 (Nondisplaced Type II dens fracture).

“Clinically, the direction of displacement has both treatment implications as well as prognostic influence on healing rates,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Dens fracture defined: Dens is an upward extension or protuberance from the superior surface of the axis or 2nd cervical vertebra. It exhibits a slight constriction or neck, where it joins the main body of the C2 vertebra. The condition, where the dens is separated from the body of the axis may cause nerve and circulation compression syndrome. There are three types of dens- related fractures:

• Type I Fracture: Extends through the tip of the dens. This type is usually stable.
• Type II Fracture: Extends through the base of the dens. It is the most commonly encountered fracture for this region of the axis. This type is the least stable and may require surgery.
• Type III Fracture: Extends through the vertebral body of the axis. This type can be stable or unstable, but is typically treatable with rigid external immobilization and less commonly requires surgery.