ICD-10 Coding for Above Knee Amputation(Z89.611, Z89.612, Z89.619)
Complete ICD-10-CM coding and documentation guide for Above Knee Amputation. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Above Knee Amputation
Z89.61Primary Range
Acquired absence of leg above knee
Primary range for documenting the status of an above knee amputation without complications.
Traumatic amputation of leg at or above knee
Used for acute traumatic amputations requiring active treatment.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z89.611 | Acquired absence of right leg above knee | Use for patients with a history of right above knee amputation without complications. |
|
| Z89.612 | Acquired absence of left leg above knee | Use for patients with a history of left above knee amputation without complications. |
|
| Z89.619 | Acquired absence of unspecified leg above knee | Use only when laterality is not documented. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for right above knee amputation
Essential facts and insights about Above Knee Amputation
Primary ICD-10-CM Codes for above knee amputation
Decision Criteria
clinical Criteria
- Patient has a history of right leg amputation above the knee.
Applicable To
- Right above knee amputation
Excludes
- Traumatic amputation (S78.021A)
Clinical Validation Requirements
- Documented history of right leg amputation above the knee
- No active treatment required
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure documentation specifies laterality and absence of complications.
Z89.612 - Acquired absence of left leg above knee
Use for patients with a history of left above knee amputation without complications.
Applicable To
- Left above knee amputation
Excludes
- Traumatic amputation (S78.022A)
Clinical Validation Requirements
- Documented history of left leg amputation above the knee
- No active treatment required
Coding Notes
Ensure documentation specifies laterality and absence of complications.
Z89.619 - Acquired absence of unspecified leg above knee
Use only when laterality is not documented.
Applicable To
- Above knee amputation, unspecified side
Excludes
- Specific laterality codes (Z89.611, Z89.612)
Clinical Validation Requirements
- Documented history of leg amputation above the knee without specified laterality
Coding Notes
Avoid using unspecified codes when laterality is known.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Traumatic amputation of right leg at or above knee, initial encounter
S78.021ATraumatic amputation of left leg at or above knee, initial encounter
S78.022AAcquired absence of right leg above knee
Z89.611Acquired absence of left leg above knee
Z89.612Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Above Knee Amputation to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z89.611.
Impact
Clinical: Inaccurate patient care records, Regulatory: Non-compliance with coding standards, Financial: Potential loss of reimbursement for prosthetic care
Mitigation Strategy
Always check for prosthetic use during follow-up visits, Ensure documentation includes prosthetic details
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit and non-compliance., Data Quality: Reduces accuracy of patient records.
Mitigation Strategy
Always document and code the specific laterality (right or left).
Impact
Reimbursement: Incorrect coding may affect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient history documentation.
Mitigation Strategy
Use S78.02xA for acute traumatic amputations and Z89.61x for acquired absence.
Impact
Using unspecified codes when laterality is documented.
Mitigation Strategy
Always document and code the specific laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Above Knee Amputation, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Above Knee Amputation
Use these documentation templates to ensure complete and accurate documentation for Above Knee Amputation. These templates include all required elements for proper coding and billing.
Post-Amputation Follow-Up
Specialty: OrthopedicsRequired Elements
- Patient history of amputation
- Laterality and level of amputation
- Presence and condition of prosthetic
- Underlying conditions (e.g., diabetes, PAD)
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Above Knee Amputation? Ask your questions below.