Injury of nerve root of sacral spine, subsequent encounter

This code describes an injury to a nerve root originating from the sacral spine, occurring during a follow-up visit for a previously diagnosed injury. This typically involves damage to the nerve fibers as they exit the sacral spinal cord, often resulting in pain, numbness, weakness, or altered reflexes in the lower extremities or pelvic region.

Use this code for encounters where a patient is receiving active treatment for a sacral nerve root injury after the initial treatment phase, or during the healing and recovery phase. This includes follow-up appointments for physical therapy, medication management, or monitoring of symptoms related to the original injury.

• Ensure documentation clearly indicates a subsequent encounter for the sacral nerve root injury.
• Verify the injury is specifically to a nerve root of the sacral spine, not other spinal regions or peripheral nerves.
• Always sequence this code after the primary diagnosis for the underlying cause of the injury, if applicable.