Complete lesion at C5 level of cervical spinal cord, init

This code signifies a severe, irreversible injury to the cervical spinal cord at the C5 vertebral level, resulting in a complete loss of motor and sensory function below that point. This type of lesion typically leads to tetraplegia, affecting all four limbs and the torso, with varying degrees of respiratory compromise.

Apply this code for initial encounters involving patients diagnosed with a traumatic complete transection or severe compression of the spinal cord at the C5 level. Documentation should clearly indicate the C5 level, the completeness of the lesion (e.g., ASIA Impairment Scale A), and that this is the first time the patient is receiving active treatment for this specific injury.

• Ensure the documentation specifies "complete lesion" and the exact C5 level; differentiate from incomplete lesions.
• Verify that this is indeed the "initial encounter" for active treatment of the injury, not a subsequent visit for follow-up care.
• Consider co-reporting with external cause codes (e.g., Y92.9, W00-X58) to describe the circumstances of the injury.