Complete lesion at T11-T12, subs

This code signifies a complete transection or severe damage to the spinal cord at the T11-T12 vertebral level, resulting in a total loss of motor and sensory function below that point. The "subsequent encounter" indicates that the patient is receiving follow-up care for this previously diagnosed injury, not the initial treatment.

This code is appropriate for documenting ongoing management, rehabilitation, or long-term care for a patient with a complete thoracic spinal cord injury at the T11-T12 level. It should be used after the initial acute phase of treatment has concluded. Examples include physical therapy sessions, medication management for complications, or routine check-ups related to the injury.

• Ensure the documentation clearly specifies a complete lesion at the T11-T12 level.
• Verify that the encounter is for follow-up care and not the initial treatment of the injury.
• Always code any associated neurological deficits or complications separately.