Complete lesion at C4 level of cervical spinal cord, sequela

This code signifies a chronic or late effect of 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. It indicates a permanent neurological deficit following an initial injury.

Apply this code for patients presenting with long-term complications or permanent neurological deficits from a past complete spinal cord injury at C4. Documentation should clearly state "sequela," "late effect," or indicate a chronic condition resulting from a complete C4 lesion.

• Requires a seventh character "S" to denote sequela, indicating a late effect of the injury.
• Do not use for acute or initial injury encounters; those require an "A" (initial encounter) or "D" (subsequent encounter) seventh character.
• Always sequence this code after the primary diagnosis describing the specific complication or condition being treated, if applicable.