Complete lesion at C2 level of cervical spinal cord, sequela

This code signifies a complete transection or severe damage to the spinal cord at the C2 vertebral level, resulting in a total loss of motor and sensory function below that point. The "sequela" designation indicates that this is a long-term or residual effect of an initial injury, not the acute injury itself. Patients typically present with quadriplegia and respiratory compromise.

Use this code for patients presenting with chronic or long-standing neurological deficits directly attributable to a complete spinal cord injury at the C2 level. Documentation should clearly state the completeness of the lesion and its location at C2, often referencing a past injury date or indicating a stable, non-acute condition. This code is appropriate for follow-up care, rehabilitation, or management of chronic complications.

• Ensure documentation specifies "complete" lesion and the exact C2 level; partial lesions or unspecified levels require different codes.
• The "S" seventh character indicates sequela; do not use for initial encounters or acute injuries.
• Always code any associated neurological deficits (e.g., quadriplegia) or complications (e.g., neurogenic bladder) in addition to this code.