Complete lesion at C6 level of cervical spinal cord, subs

This code signifies a complete transection or severe damage to the cervical spinal cord at the C6 vertebral level, resulting in a total loss of motor and sensory function below that point. This specific code indicates that the patient is in the healing phase following the initial injury, or receiving ongoing treatment for its sequelae.

Use this code for follow-up encounters, such as rehabilitation sessions, medication management, or monitoring of complications, after the initial treatment of a complete C6 spinal cord injury. Documentation should clearly state the C6 level, the completeness of the lesion, and indicate that it is not the initial treatment phase.

• Ensure documentation specifies "complete lesion" and the C6 level; partial lesions or unspecified levels require different codes.
• The "D" seventh character indicates a subsequent encounter; use "A" for initial encounters and "S" for sequela.
• Always code any associated neurological deficits (e.g., quadriplegia) separately and in conjunction with this code.