Complete lesion of sacral spinal cord, subsequent encounter

This code signifies a complete transection or severe damage to the sacral spinal cord, resulting in a total loss of motor and sensory function below the level of the injury. It indicates that the patient is in a phase of treatment or recovery following the initial acute injury.

Apply this code for follow-up visits, rehabilitation encounters, or ongoing management of a patient previously diagnosed with a complete sacral spinal cord lesion. This includes scenarios where the patient is receiving physical therapy, occupational therapy, or medical management for long-term complications.

• Ensure documentation clearly specifies "complete" lesion and "sacral" level.
• Verify that the encounter is not for the initial treatment of the injury; use the appropriate initial encounter code for that.
• Look for documentation of ongoing care, such as medication management for spasticity or bladder/bowel dysfunction, related to the spinal cord injury.