Central cord syndrome at C6, sequela

This code signifies the long-term effects or complications arising from a central cord syndrome injury specifically located at the C6 level of the cervical spinal cord. Central cord syndrome typically involves greater motor impairment in the upper extremities than in the lower extremities, along with varying degrees of sensory loss and bladder dysfunction. The "sequela" designation indicates that this code is used for conditions that are residual or chronic after the initial injury has healed.

This code is appropriate for encounters where a patient is being treated for the chronic or residual neurological deficits resulting from a past central cord syndrome injury at C6. Documentation should clearly state the C6 level involvement and indicate that the current condition is a long-term consequence of the original injury, rather than an acute injury. Examples include ongoing weakness, spasticity, sensory deficits, or neuropathic pain directly attributable to the prior C6 central cord injury.

• Always ensure documentation specifies "sequela" or "late effect" to justify the 7th character 'S'.
• Do not use this code for acute central cord syndrome; refer to the acute injury codes in the S14.12- series.
• Code any specific residual neurological deficits (e.g., spasticity, paralysis) in addition to this sequela code, following the guidelines for coding sequelae.