Oth incomplete lesion at C4, sequela

This code signifies a long-term effect or complication arising from a previous incomplete spinal cord injury at the C4 vertebral level, where some motor or sensory function below the injury site is preserved. It indicates that the initial acute injury has resolved, but residual neurological deficits persist.

Use this code when documenting chronic neurological impairments, such as weakness, spasticity, or sensory loss, directly attributable to an old, incomplete C4 spinal cord injury. Documentation should clearly state the injury is "old," "healed," or describe persistent deficits from a past event, and specify the C4 level and incomplete nature.

• This "S" seventh character indicates a sequela, meaning it's used for complications or conditions arising as a direct result of a previous injury, not the initial acute injury.
• Ensure documentation explicitly states the C4 level and that the lesion is incomplete; avoid using for complete lesions or unspecified levels.
• Always sequence this code after the primary diagnosis for the current encounter, if applicable, or as the primary diagnosis if the sequela is the reason for the visit.