Complete lesion of L4 level of lumbar spinal cord, init

This code signifies a total transection or complete functional disruption of the spinal cord at the L4 vertebral level in the lumbar region. This results in a complete loss of motor and sensory function below the level of the injury.

Apply this code for patients presenting with a newly diagnosed, complete spinal cord injury at the L4 level. This is appropriate for the initial evaluation and treatment of such an injury, often following a traumatic event.

• Ensure documentation clearly specifies "complete lesion" and the L4 level.
• Verify this is the "initial encounter" for treatment of the injury. Subsequent encounters will require a different seventh character.
• Always code any associated external cause of injury (e.g., fall, motor vehicle accident) in addition to this diagnosis.