Complete lesion at unsp level of thoracic spinal cord, init

This diagnosis indicates a complete transection or severe damage to the thoracic spinal cord, resulting in a total loss of motor and sensory function below the injury site. The specific vertebral level within the thoracic spine is not documented or is unknown at the time of this initial assessment.

This code is appropriate for the initial encounter with a patient presenting with a newly diagnosed, complete spinal cord injury affecting the thoracic region, where the precise level of the lesion has not yet been determined or specified in the medical record. It is used when the documentation clearly states "complete" but lacks a specific T-level.

• Only use this code for the initial encounter of the injury. Subsequent encounters will require a different seventh character.
• Avoid this code if a specific thoracic vertebral level (e.g., T1, T12) is documented for the complete lesion.
• Ensure documentation explicitly states "complete lesion" to support the use of this code.