Complete lesion at unsp level of cervical spinal cord, init

This code signifies a complete transection or severe damage to the cervical spinal cord, resulting in a total loss of motor and sensory function below the level of injury. The specific vertebral level of the cervical spine affected is not documented or is unknown. This injury typically leads to quadriplegia.

This code is appropriate for initial encounters when a patient presents with a complete cervical spinal cord injury, and the precise anatomical level of the lesion has not yet been determined or documented. It is used when the medical record clearly indicates a complete functional deficit below the neck, but imaging or neurological examination has not pinpointed the exact vertebral segment. Documentation should explicitly state "complete lesion" and "cervical spinal cord."

• Do not use this code if the specific cervical vertebral level (e.g., C1, C2, C3) of the complete lesion is known and documented; instead, use the more specific S14.11- codes.
• This code is for an "initial encounter" only. For subsequent care, use the appropriate S14.119D (subsequent encounter) or S14.119S (sequela) codes.
• Ensure documentation differentiates between a "complete" and "incomplete" lesion, as different codes apply to incomplete injuries.