Injury of nerve root of lumbar spine, subsequent encounter

This diagnosis code indicates an injury to a nerve root originating from the lumbar spine that is being treated during a follow-up visit. This could involve damage to the nerve itself, such as a compression, stretch, or contusion, occurring at the level of the lower back. The injury results in symptoms like pain, numbness, weakness, or altered reflexes in the distribution of the affected nerve.

Apply this code when a patient presents for ongoing management, evaluation, or treatment of a previously diagnosed lumbar nerve root injury. This includes follow-up appointments for physical therapy, medication adjustments, or monitoring recovery after an initial injury or surgical intervention. It is appropriate for encounters occurring after the initial acute phase of the injury.

• Ensure documentation clearly specifies "subsequent encounter" or similar language indicating ongoing care.
• Always code the underlying cause of the nerve root injury (e.g., fracture, disc herniation) as a primary diagnosis if applicable and still being treated.
• Do not use this code for initial treatment of a new injury; instead, use the appropriate "initial encounter" code.