Complete lesion at T1 level of thoracic spinal cord, subs

This code signifies a complete transection or severe damage to the spinal cord at the T1 vertebral level, resulting in a total loss of motor and sensory function below that point. The "complete lesion" indicates no preserved neurological function distal to the injury site.

This code is appropriate for follow-up encounters with patients who have previously been diagnosed and are receiving ongoing treatment for a complete T1 spinal cord injury. This includes rehabilitation visits, medication management, or monitoring for complications related to the initial injury.

• Ensure documentation clearly states "complete lesion" and specifies the T1 level.
• The "D" seventh character indicates a subsequent encounter, meaning the patient is in the healing or recovery phase.
• Do not use for initial injury encounters; a different seventh character would be required.