Complete lesion of L4 level of lumbar spinal cord, sequela

This code signifies a complete transection or severe damage to the L4 spinal cord segment, resulting in a total loss of motor and sensory function below that level. As a sequela code, it indicates that the initial injury occurred in the past and the patient is now experiencing the long-term effects or complications of that damage.

Use this code for patients presenting with chronic neurological deficits, such as paraplegia or significant motor and sensory impairment, directly attributable to a past complete spinal cord injury at the L4 level. This applies when the acute phase of the injury has passed and the current encounter addresses the residual conditions.

• Ensure documentation clearly states "complete lesion" and specifies the L4 level.
• The "S" at the end indicates a sequela code; only use this for conditions that are residual effects of a past injury.
• Always code the underlying cause of the spinal cord injury if it is still relevant and documented.