Complete lesion at C1 level of cervical spinal cord, subs

This code signifies a complete transection or severe damage to the spinal cord at the C1 vertebral level, resulting in a total loss of motor and sensory function below this point. It indicates that the patient is in the healing or recovery phase following the initial injury.

Use this code for follow-up encounters when a patient is receiving ongoing care for a previously diagnosed complete C1 spinal cord lesion. Documentation should clearly state the C1 level, the completeness of the lesion, and indicate that the encounter is not for the initial acute injury. This code is appropriate for rehabilitation, medication management, or monitoring of long-term complications.

• Ensure documentation specifies "complete lesion" and the C1 level; partial lesions or unspecified levels require different codes.
• The "D" seventh character indicates a subsequent encounter; use "A" for the initial encounter and "S" for sequela.
• Always code any associated neurological deficits or complications (e.g., quadriplegia, respiratory paralysis) in addition to this code.