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ICD-10 Coding for Above-the-Knee Amputation(Z89.61x, Z89.62x)

Complete ICD-10-CM coding and documentation guide for Above-the-Knee Amputation. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

AKATransfemoral Amputation

Related ICD-10 Code Ranges

Complete code families applicable to Above-the-Knee Amputation

Z89.6Primary Range

Acquired absence of leg above knee

This range covers the primary codes for documenting the absence of a leg above the knee due to various causes such as trauma, illness, or surgery.

Phantom limb syndrome

These codes are used to document complications such as phantom limb syndrome that may occur after an amputation.

Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene

This code is used to document diabetes as an underlying condition leading to amputation.

Atherosclerosis of native arteries of extremities with gangrene

This code is used to document peripheral vascular disease as an underlying condition leading to amputation.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
Z89.61xAcquired absence of right leg above kneeUse for documenting the status of a right leg amputation above the knee.
  • Operative note confirming amputation level
  • Imaging or clinical documentation of underlying cause
Z89.62xAcquired absence of left leg above kneeUse for documenting the status of a left leg amputation above the knee.
  • Operative note confirming amputation level
  • Imaging or clinical documentation of underlying cause

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 above the knee amputation

Essential facts and insights about Above-the-Knee Amputation

The ICD-10 code for an above the knee amputation is Z89.61x for the right leg and Z89.62x for the left leg.

Primary ICD-10-CM Codes for above the knee amputation

Acquired absence of right leg above knee
Non-billable Code

Decision Criteria

documentation Criteria

  • Document the level and laterality of the amputation.

Applicable To

  • Right leg amputation above knee

Excludes

  • Congenital absence of limb

Clinical Validation Requirements

  • Operative note confirming amputation level
  • Imaging or clinical documentation of underlying cause

Code-Specific Risks

  • Ensure laterality is correctly documented.

Coding Notes

  • Annual documentation of the amputation status is required.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Phantom limb syndrome with pain

G54.6
Use when the patient experiences phantom limb pain post-amputation.

Phantom limb syndrome without pain

G54.7
Use when the patient experiences phantom sensations without pain post-amputation.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Acquired absence of left leg above knee

Z89.62x
Differentiate based on laterality.

Acquired absence of right leg above knee

Z89.61x
Differentiate based on laterality.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Above-the-Knee Amputation to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z89.61x.

Impact

Clinical: Incomplete clinical picture., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims.

Mitigation Strategy

Always include codes for underlying conditions like diabetes or PVD.

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.

Mitigation Strategy

Always include the correct laterality in the code (e.g., Z89.611 for right leg).

Impact

Failure to document the level and laterality of amputation can lead to audit issues.

Mitigation Strategy

Implement a checklist for documenting all required elements.

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-the-Knee Amputation, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Above-the-Knee Amputation

Use these documentation templates to ensure complete and accurate documentation for Above-the-Knee Amputation. These templates include all required elements for proper coding and billing.

Post-operative documentation for AKA

Specialty: Vascular Surgery

Required Elements

  • Amputation level and laterality
  • Underlying condition
  • Prosthetic device status
  • Complications such as phantom limb pain

Examples: Poor vs. Good Documentation

Poor Documentation Example
AKA status. Prosthetic leg.
Good Documentation Example
Acquired absence of left leg above knee due to PVD, status post surgical amputation 03/2024. Uses exoskeletal prosthesis. Phantom pain managed with gabapentin.
Explanation
The good example provides specific details about the amputation, underlying condition, prosthetic use, and management of complications.

Need help with ICD-10 coding for Above-the-Knee Amputation? Ask your questions below.

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