Complete lesion of sacral spinal cord, sequela

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 lesion. This injury permanently disrupts nerve signals to and from the lower extremities, bladder, bowel, and sexual organs. The "sequela" designation indicates that this code is used for the long-term effects or complications of the original injury, not the acute event itself.

This code is appropriate for documenting the chronic, permanent neurological deficits resulting from a complete sacral spinal cord injury. It should be used when a patient is being treated for ongoing conditions directly attributable to this past injury, such as neurogenic bladder, chronic pain, or paralysis of the lower limbs. This code is not for the initial injury or its immediate post-acute care.

• Always use this code as a secondary diagnosis, following the code for the specific condition being treated that is a sequela of the spinal cord injury.
• Ensure documentation clearly states the completeness of the lesion and its sacral location.
• The "S" at the end of the code indicates a sequela, meaning it's for conditions arising as a direct result of a previous injury, not the acute injury itself.