Complete lesion at C5 level of cervical spinal cord, sequela

This code signifies a complete transection or severe damage to the spinal cord at the C5 vertebral level, resulting in a total loss of motor and sensory function below that point. The "sequela" seventh character indicates that this code is for a late effect or complication of an earlier injury, not the initial acute injury itself. Patients typically present with quadriplegia affecting all four limbs, trunk, and respiratory muscles to varying degrees, depending on the exact C5 involvement.

Use this code for patients presenting with chronic neurological deficits directly attributable to a past complete spinal cord injury at the C5 level. Documentation should clearly state a history of complete C5 SCI and the current neurological status reflecting the permanent impairment. This code is appropriate for follow-up visits, rehabilitation, or management of long-term complications.

• Always ensure the documentation specifies "complete lesion" and the C5 level.
• The "S" seventh character is crucial and indicates a sequela; do not use for acute injuries.
• Consider additional codes for specific complications arising from the SCI, such as neurogenic bladder (N31.x), pressure ulcers (L89.xxx), or spasticity (G80.x).