AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2024 Issue 2; Ask the Editor

Cervical Fracture with Central Cord Syndrome and Incomplete Quadriplegia due to Traumatic Injury

A patient was transferred to our facility due to onset of quadriparesis following a fall on ground level two days earlier. The patient was diagnosed with C2 fracture and central cord syndrome at C3-4 and C4-5. The provider documented that the patient remained with incomplete quadriplegia status post C3 and C4 laminectomies. When referencing “quadriplegia, traumatic” in the Alphabetic index, there is a coding instruction to “see Injury, spinal (cord), cervical.” This appears to indicate that only a spinal injury code is reported when quadriplegia is associated with an injury. However, when referencing “quadriplegia, incomplete,” code G82.52, Quadriplegia, C1-C4, incomplete, is provided for this condition at levels C1-C4. What are the appropriate code assignments for incomplete quadriplegia in a patient with a C2 fracture and central cord syndrome (CCS)? ...

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