G83.4
BillableCauda equina syndrome
HCC Category Mapping
V28HCC 182 — Spinal Cord Disorders/Injuries
0.282V24HCC 72 — Spinal Cord Disorders/Injuries
0.464ESRDHCC 72 — Spinal Cord Disorders/Injuries
0.000RxHCCHCC 155 — Myelitis and Encephalomyelitis
0.000What This Code Means
A serious condition where the bundle of nerves at the base of the spinal cord is compressed or damaged, causing weakness or loss of function in the legs and loss of bladder/bowel control.
Coding Tips
- •Document the underlying cause (herniated disc, trauma, tumor) as it may affect treatment and prognosis coding
- •This is a medical emergency requiring immediate intervention; ensure acute presentation is captured if applicable
Clinical Significance
Cauda equina syndrome is a surgical emergency caused by compression of the nerve bundle at the base of the spinal cord, resulting in lower extremity weakness, saddle anesthesia, and bowel/bladder dysfunction. Early recognition and surgical decompression are critical to prevent permanent neurological damage. This condition drives significant acute care resource utilization and often results in long-term functional deficits requiring ongoing management.
Documentation Requirements
- ✓Diagnosis of cauda equina syndrome explicitly stated
- ✓Underlying cause (disc herniation, tumor, abscess, fracture, etc.)
- ✓Neurological findings: saddle anesthesia, lower extremity weakness/numbness
- ✓Bladder and bowel function status (retention, incontinence)
- ✓Surgical intervention documentation if performed
- ✓Acute vs. chronic presentation status
- ✓Ongoing residual deficits if present
- ✓Active follow-up and management plan
Commonly Confused Codes
G82.20 Paraplegia, unspecified — bilateral lower extremity paralysis without cauda equina involvementM51.16 Intervertebral disc disorder with radiculopathy, lumbar — disc disease without cauda equina compressionM48.06 Spinal stenosis, lumbar — narrowing without cauda equina involvementG95.89 Other specified diseases of spinal cord — other spinal cord conditionsS34.3 Injury of cauda equina — use for traumatic injury to the cauda equina