ICD-10 Coding for Below Knee Amputation(Z89.511, Z89.512, Z89.519)
Complete ICD-10-CM coding and documentation guide for Below Knee Amputation. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Below Knee Amputation
Z89.5Primary Range
Acquired absence of limb
This range includes codes for acquired absence of limbs, specifically below knee amputations.
Type 2 diabetes mellitus with circulatory complications
Relevant when diabetes is the underlying cause of the amputation.
Atherosclerosis of native arteries of the extremities
Used when peripheral vascular disease is the cause of the amputation.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z89.511 | Acquired absence of right leg below knee | Use for patients with a right below knee amputation without active disease. |
|
| Z89.512 | Acquired absence of left leg below knee | Use for patients with a left below knee amputation without active disease. |
|
| Z89.519 | Acquired absence of unspecified leg below knee | Use only when laterality cannot be determined from the documentation. |
|
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 below knee amputation
Essential facts and insights about Below Knee Amputation
Primary ICD-10-CM Codes for below knee amputation
Decision Criteria
clinical Criteria
- Patient has undergone a surgical amputation of the right leg below the knee.
documentation Criteria
- Operative report and radiographic evidence confirm the amputation.
Applicable To
- Right below knee amputation
Excludes
- Congenital absence of limb
Clinical Validation Requirements
- Operative report confirming right leg amputation below knee
- Radiographic evidence of tibia/fibula resection
Code-Specific Risks
- Incorrect laterality documentation
- Missing underlying condition codes
Coding Notes
- Ensure laterality is specified in the documentation.
Z89.512 - Acquired absence of left leg below knee
Use for patients with a left below knee amputation without active disease.
Applicable To
- Left below knee amputation
Excludes
- Congenital absence of limb
Clinical Validation Requirements
- Operative report confirming left leg amputation below knee
- Radiographic evidence of tibia/fibula resection
Coding Notes
Ensure laterality is specified in the documentation.
Z89.519 - Acquired absence of unspecified leg below knee
Use only when laterality cannot be determined from the documentation.
Applicable To
- Below knee amputation, unspecified laterality
Excludes
- Congenital absence of limb
Clinical Validation Requirements
- Documentation does not specify laterality of the amputation.
Coding Notes
Query provider for laterality if possible.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Non-pressure chronic ulcer of lower limb, not elsewhere classified
L97.4Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Complete traumatic amputation at level between knee and ankle, right leg, initial encounter
S88.011AComplete traumatic amputation at level between knee and ankle, left leg, initial encounter
S88.012AComplete traumatic amputation at level between knee and ankle, unspecified leg, initial encounter
S88.019ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Below Knee Amputation to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z89.511.
Impact
Clinical: Impacts treatment planning and prosthetic fitting., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Always verify laterality in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect laterality can affect DRG assignment and reimbursement., Compliance: May lead to compliance issues if laterality is not documented., Data Quality: Affects the accuracy of patient records and data analytics.
Mitigation Strategy
Query provider to specify right or left BKA for accurate coding.
Impact
Reimbursement: Omitting these codes can lead to lower reimbursement rates., Compliance: Failure to document underlying conditions can result in audit issues., Data Quality: Reduces the accuracy of clinical data and risk adjustment scores.
Mitigation Strategy
Ensure to include codes for conditions like diabetes or PVD when applicable.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Implement documentation checks and use templates that require 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 Below Knee Amputation, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Below Knee Amputation
Use these documentation templates to ensure complete and accurate documentation for Below Knee Amputation. These templates include all required elements for proper coding and billing.
Post-Operative Documentation for BKA
Specialty: OrthopedicsRequired Elements
- Amputation level and laterality
- Underlying condition
- Residual limb status
- Prosthetic use
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Below Knee Amputation? Ask your questions below.