Cauda equina syndrome

This code represents a rare but serious neurological condition characterized by compression of the cauda equina nerves at the end of the spinal cord. This compression leads to a constellation of symptoms affecting the lower extremities, bladder, and bowel function.

Assign this code when documentation explicitly states a diagnosis of cauda equina syndrome. This typically involves acute onset of severe low back pain, saddle anesthesia, bowel/bladder dysfunction (e.g., urinary retention, incontinence), and lower extremity weakness or sensory deficits.

• Do not confuse with general spinal cord compression without specific cauda equina involvement.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter.
• Ensure documentation clearly supports the diagnosis, including specific neurological deficits.