Complete lesion at C5 level of cervical spinal cord, subs

This code signifies a complete transection or severe damage to the spinal cord at the C5 vertebral level, resulting in a total loss of motor and sensory function below that point. It indicates a subsequent phase of care for this specific injury, following the initial acute treatment.

Apply this code for follow-up encounters, rehabilitation sessions, or long-term management of a patient previously diagnosed with a complete C5 spinal cord injury. Documentation should clearly state the C5 level, the completeness of the lesion, and that the encounter is not for the initial injury.

• Ensure documentation specifies "complete" lesion; partial lesions at C5 use different codes.
• Verify the encounter is "subsequent" (D seventh character) and not initial (A) or sequela (S).
• Always sequence this code after any acute conditions being treated during the subsequent encounter.