Complete lesion at C4 level of cervical spinal cord, init

This code signifies a complete transection or severe damage to the spinal cord at the C4 vertebral level, resulting in a total loss of motor and sensory function below that point. This type of injury typically leads to quadriplegia, affecting all four limbs and often respiratory function.

Apply this code for the initial encounter of a patient presenting with a confirmed complete spinal cord injury at the C4 level. Documentation should clearly state the C4 level involvement and the complete nature of the lesion, often evidenced by neurological examination findings such as absent reflexes and sensation below the injury.

• Ensure documentation specifies "complete lesion" and the exact cervical level (C4).
• Do not confuse with incomplete lesions (S14.12- series) or injuries at different cervical levels.
• Remember the "A" seventh character for initial encounter; subsequent care will require different seventh characters.