Injury to spine and spinal cord due to birth trauma

This code signifies damage to the vertebral column or its neural contents that occurs during the process of childbirth. This can range from fractures or dislocations of the vertebrae to contusions, lacerations, or compression of the spinal cord itself, resulting from mechanical forces during delivery.

Apply this code when documentation clearly indicates a spinal or spinal cord injury in a neonate directly attributable to the birthing process. This includes cases involving difficult deliveries, instrumental deliveries, or fetal malposition leading to trauma. Supporting documentation should specify the nature of the injury and its direct link to birth.

• Ensure the documentation explicitly states the injury occurred due to birth trauma; otherwise, consider other codes for congenital or acquired spinal conditions.
• Do not use this code for spinal anomalies present at birth that are not a direct result of the delivery process.
• Sequence this code as a primary diagnosis when it is the main reason for admission or treatment.