G95.81

HCC Category Mapping

What This Code Means

A syndrome affecting the lowest part of the spinal cord (conus medullaris) that causes loss of bowel and bladder control, sexual dysfunction, and leg weakness.

Coding Tips

• •Identify the underlying cause (trauma, tumor, disc herniation) and code separately
• •Document specific neurological deficits including bowel/bladder dysfunction and lower extremity weakness

Clinical Significance

Conus medullaris syndrome results from damage to the terminal end of the spinal cord (conus medullaris), typically at the T12-L2 vertebral level, causing a characteristic pattern of lower motor neuron dysfunction in the legs, bowel and bladder dysfunction, and saddle anesthesia. It is distinguished from cauda equina syndrome by its more symmetric presentation and upper motor neuron signs. This condition requires urgent diagnosis and treatment to prevent permanent neurological damage.

Documentation Requirements

• ✓MRI demonstrating pathology at the conus medullaris (T12-L2 vertebral level)
• ✓Neurological examination documenting symmetric lower extremity weakness, saddle anesthesia, and sphincter dysfunction
• ✓Identification of the underlying cause (disc herniation, tumor, vascular event, trauma)
• ✓Bowel and bladder function assessment
• ✓Treatment plan and surgical intervention details if applicable

Commonly Confused Codes