Complete lesion at T2-T6, sequela

This code signifies a complete transection or severe damage to the thoracic spinal cord, specifically affecting the T2 through T6 vertebral levels. A complete lesion means there is a total loss of motor and sensory function below the injury site. "Sequela" indicates that this code is used for the long-term effects or complications of the original injury, not the initial acute event.

This code is appropriate for documenting the permanent neurological deficits resulting from a complete spinal cord injury at the T2-T6 level, such as paraplegia, loss of sensation, or autonomic dysfunction. It should be used in follow-up encounters for chronic care, rehabilitation, or management of ongoing complications related to the past injury. Do not use this code for the initial acute injury.

• Always ensure documentation clearly states "complete lesion" and specifies the T2-T6 thoracic level.
• Verify the encounter is for the long-term effects (sequela) of the injury, not the initial treatment.
• Code any associated conditions or complications, such as pressure ulcers or neurogenic bladder, in addition to this code.