Shaken infant syndrome, subsequent encounter

This code signifies a diagnosis of Shaken Infant Syndrome (SIS) when the patient is receiving follow-up care, such as ongoing treatment, monitoring, or rehabilitation, after the initial acute phase of the injury. SIS is a severe form of abusive head trauma in infants and young children, resulting from violent shaking, often leading to subdural hematomas, retinal hemorrhages, and brain injury.

Apply this code for encounters where a previously diagnosed case of SIS is being managed. This includes visits for physical therapy, occupational therapy, speech therapy, neurological follow-ups, or psychological counseling related to the sequelae of the original injury. It is appropriate for any encounter after the initial treatment of the acute injury.

• Always sequence this code after the specific codes for the injuries sustained due to SIS (e.g., subdural hemorrhage, retinal hemorrhage).
• Ensure documentation clearly indicates that the encounter is for ongoing care or follow-up related to a past SIS diagnosis.
• Do not use this code for the initial acute presentation of SIS; refer to the 'A' (initial encounter) or 'B' (subsequent encounter for fracture care) seventh characters for those scenarios.