Secondary progressive multiple sclerosis, unspecified

This code signifies a diagnosis of secondary progressive multiple sclerosis (SPMS) where the specific clinical course or progression details are not further specified. SPMS is a form of multiple sclerosis that typically follows an initial relapsing-remitting course, characterized by a gradual, steady worsening of neurological function over time, with or without occasional relapses or minor remissions.

Use this code when documentation clearly indicates a diagnosis of secondary progressive multiple sclerosis without further specification of its activity or progression. This code is appropriate when the provider has diagnosed SPMS but has not documented whether it is active, inactive, or in remission.

• Ensure the documentation explicitly states "secondary progressive multiple sclerosis" and lacks further specificity regarding its activity.
• Do not use this code if the documentation specifies active, inactive, or in remission SPMS; instead, use the more specific codes within the G35.C- category.
• Always review the entire medical record to confirm the most precise diagnosis of multiple sclerosis type and activity.