Closed fracture of sacrum and coccyx without mention of spinal cord injury

This code signifies a break in the sacrum or coccyx bones, located at the base of the spine, where the skin remains intact over the fracture site. It specifically indicates that there is no associated damage to the spinal cord. This injury can result in significant pain and functional limitations.

Apply this code when documentation confirms a fracture of the sacrum or coccyx, and the physician explicitly states or implies that the fracture is closed (no open wound communicating with the fracture). Crucially, the medical record must also clearly indicate the absence of any spinal cord involvement.

• Ensure documentation explicitly rules out an open fracture to avoid miscoding.
• Verify that there is no mention of neurological deficits or spinal cord injury to differentiate from codes that include such complications.
• Consider sequencing this code as a primary diagnosis if it is the main reason for the encounter, or as a secondary diagnosis if it's a co-morbidity.