Oth incomplete lesion at T2-T6, sequela

This code signifies a long-term neurological deficit resulting from a past incomplete injury to the thoracic spinal cord, specifically affecting the T2-T6 vertebral levels. An incomplete lesion means that some motor or sensory function below the injury level is preserved, rather than a complete loss. The "sequela" designation indicates that this is a residual condition or complication of an initial injury that occurred in the past.

Use this code when documenting the chronic, residual effects of an incomplete spinal cord injury to the mid-thoracic region (T2-T6). This applies to patients presenting for follow-up care, rehabilitation, or management of ongoing symptoms directly attributable to the historical injury. It should be used when the acute phase of the injury has passed and the patient is experiencing lasting neurological impairments.

• Always ensure documentation clearly states "incomplete" lesion and specifies the T2-T6 level.
• Verify that the encounter is for the sequela (late effect) of the injury, not an acute injury.
• Code also any associated neurological deficits (e.g., muscle weakness, sensory loss) if documented.