Non-active secondary progressive multiple sclerosis

This code signifies a stage of multiple sclerosis (MS) where there is a sustained, gradual worsening of neurological function after an initial relapsing-remitting course, but without active inflammation or new lesion formation detectable on imaging. It represents a period of disease progression without acute relapses or evidence of current disease activity.

Use this code when documentation clearly indicates a patient has secondary progressive MS that is currently stable and not experiencing a relapse or new MRI activity. This diagnosis is typically made after a period of relapsing-remitting MS, followed by a sustained decline in neurological function independent of relapses. Supporting documentation includes neurological exam findings, patient history, and MRI reports confirming no new T2 lesions or gadolinium-enhancing lesions.

• Differentiate carefully from "active" secondary progressive MS (G35.C1), which implies ongoing inflammatory activity or relapses.
• Ensure the physician's documentation explicitly states "non-active" or "stable" secondary progressive MS.
• Do not use this code if the patient is still in the relapsing-remitting phase or has primary progressive MS.