In simple words: This code describes the complete loss of the right shoulder and upper arm due to an injury, during a follow-up visit.The doctor will check for pain, bleeding, and infection, and may recommend treatment like pain medicine, antibiotics, and physical therapy.

This code signifies a complete traumatic amputation of the right shoulder and upper arm, where the precise level of amputation is not specified.It applies to subsequent encounters after the initial injury and amputation. The condition may present with severe pain, bleeding, numbness, damaged tissues (muscles, bones, tendons, skin), infection, fracture, laceration, nerve injury, and loss of body part. Diagnosis relies on patient history, physical examination,Mangled Extremity Severity Score, and imaging (X-rays, CT, MRI) to assess the extent of damage and the feasibility of reattachment. Treatment may involve hemorrhage control, wound debridement and repair, potential reimplantation, analgesics, antibiotics, tetanus prophylaxis, NSAIDs, physical/occupational therapy, and infection management.

Example 1: A patient presents to the emergency department after a motor vehicle accident with a complete traumatic amputation of their right shoulder and upper arm. The level of amputation is unclear due to the severity of the injury. This code would be used for subsequent encounters. , A construction worker suffers a traumatic amputation of their right shoulder and upper arm while operating heavy machinery.After initial stabilization and surgery, the patient is seen in the outpatient clinic for follow-up care, wound assessment, and pain management.S48.911D is applied., A patient is admitted to the hospital following an industrial accident resulting in the complete traumatic amputation of their right shoulder and upper arm. The amputation is at an unspecified level due to the extensive nature of the injury.S48.911D is used on subsequent hospital visits during recovery.

Detailed documentation should include the mechanism of injury, date and time of the injury, the level of amputation (even if unspecified), the presence of any complications (infection, nerve damage, etc.), imaging reports,details of surgical procedures, and notes on pain management, wound care, and rehabilitation.

** This code is specifically for subsequent encounters.The initial encounter would require a different code depending on the specifics of the injury and procedure.Always refer to the most current ICD-10-CM coding guidelines.