ICD-10 Coding for Right Above-Knee Amputation(Z89.611)
Complete ICD-10-CM coding and documentation guide for Right 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 Right Above-Knee Amputation
Z89.6-Primary Range
Acquired absence of leg above knee
This range includes codes for acquired absence of the leg above the knee, specifying laterality and level of amputation.
Key Information: ICD-10 code for right AKA
Essential facts and insights about Right Above-Knee Amputation
Primary ICD-10-CM Code for right aka
Decision Criteria
clinical Criteria
- Presence of right leg amputation above the knee joint
documentation Criteria
- Documentation of prosthetic use or surgical history
Applicable To
- Right transfemoral amputation
Excludes
- Complications of amputation stump (T87.4-)
Clinical Validation Requirements
- Operative report confirming amputation level
- Physical therapy notes documenting prosthetic use
Code-Specific Risks
- Risk of omitting laterality or level of amputation
Coding Notes
- Ensure that the documentation includes the level of amputation and any prosthetic use.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right 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 assessment of patient's mobility status., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Always document the type and condition of the prosthetic device.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate representation of patient status in medical records.
Mitigation Strategy
Use Z89.611 for status post-amputation without active complications.
Impact
Failure to document prosthetic use can lead to audit findings.
Mitigation Strategy
Ensure all prosthetic details are included in the patient's record.
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 Right Above-Knee Amputation, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Above-Knee Amputation
Use these documentation templates to ensure complete and accurate documentation for Right Above-Knee Amputation. These templates include all required elements for proper coding and billing.
Routine follow-up for right AKA
Specialty: OrthopedicsRequired Elements
- Amputation level and laterality
- Prosthetic use and condition
- Residual limb condition
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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