Complete lesion at T1 level of thoracic spinal cord, sequela

This code signifies a complete transection or severe damage to the spinal cord at the T1 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 late effect of the initial injury, not the acute event itself. Patients typically present with paraplegia, loss of sensation, and autonomic dysfunction affecting the trunk and lower extremities.

Apply this code for patients presenting with chronic or residual conditions directly attributable to a complete T1 spinal cord injury. This is appropriate for follow-up encounters, rehabilitation admissions, or when managing ongoing complications years after the initial trauma. Do not use this code for the initial acute injury.

• Always ensure documentation clearly states "complete lesion" and specifies the T1 level.
• The "S" seventh character indicates sequela; ensure this is appropriate for the encounter's timing and purpose.
• Code any associated neurological deficits or complications (e.g., neurogenic bladder, pressure ulcers) separately.