Complete lesion of sacral spinal cord, initial encounter

This code signifies a complete transection or severe disruption of the sacral spinal cord, resulting in a total loss of motor and sensory function below the level of the injury. This type of lesion typically leads to paralysis of the lower extremities, bowel, and bladder.

Apply this code for initial encounters with patients presenting with a newly diagnosed or acute complete sacral spinal cord injury. This includes traumatic injuries such as fractures or dislocations affecting the sacral spine, or non-traumatic causes like ischemia or tumors.

• Ensure documentation clearly specifies "complete lesion" and the sacral level of the spinal cord.
• Verify this is the patient's initial encounter for this specific injury, not a follow-up or sequela visit.
• Always code any associated traumatic injuries (e.g., sacral fracture) in addition to the spinal cord injury.