Complete lesion of unsp level of lumbar spinal cord, sequela

This code indicates a complete transection or severe damage to the lumbar spinal cord, resulting in a total loss of motor and sensory function below the level of the injury. The specific vertebral level within the lumbar region is not documented or is unknown. This code is used to report the long-term effects or complications of such an injury.

Apply this code when documenting the permanent neurological deficits stemming from a complete lumbar spinal cord injury, such as paraplegia or loss of bowel/bladder control, after the acute phase of treatment has concluded. This is appropriate for follow-up visits, rehabilitation, or when managing chronic conditions directly attributable to the past spinal cord trauma.

• Always use this code as a secondary diagnosis, following the primary diagnosis for the specific sequela being treated (e.g., pressure ulcer, neurogenic bladder).
• Ensure the medical record clearly indicates a complete lesion and that the injury is in the lumbar region, even if the exact level is unspecified.
• Verify that the encounter is for the sequela (late effects) of the injury, not the initial acute injury itself.