Oth incomplete lesion at T1, sequela

This code signifies a long-term consequence or late effect of an incomplete injury to the T1 level of the thoracic spinal cord, where some motor or sensory function below the injury level is preserved. The injury was not a complete transection, and the patient is now presenting with residual neurological deficits or complications stemming from that past event.

This code is appropriate for documenting the sequelae of a previously sustained, incomplete T1 spinal cord injury, such as chronic pain, spasticity, neurogenic bladder/bowel, or persistent motor/sensory deficits. It should be used when the patient is no longer in the acute phase of the injury and is being treated for the lasting effects.

• Always assign this code as a secondary diagnosis, following the code for the specific sequela being treated.
• Ensure documentation clearly states the injury was incomplete and at the T1 level.
• Confirm that the encounter is for the sequela of the injury, not the initial acute treatment.