2025 ICD-10-CM code S58.119S
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the elbow and forearm 19 Feed
Complete traumatic amputation at a level between the elbow and the wrist of an unspecified arm, sequela.
Medical necessity for services related to this code should be supported by documentation of the sequelae of the amputation, the functional limitations the patient is experiencing, and the treatment plan to address those limitations.
Clinicians should document the cause of the original injury, the long-term effects the patient is experiencing (e.g., phantom limb pain, neuroma, infection, limited mobility), and any treatment provided for these sequelae. The Mangled Extremity Severity Score can help assess the severity of the initial injury.
In simple words: This code refers to the lasting effects of a complete amputation of the forearm, between the elbow and wrist, on an unspecified arm due to an injury.It indicates that the arm has fully healed from the initial injury, but there may be long-term effects. The code doesn't indicate whether the right or left arm is affected.
This code describes the long-term consequences of a complete traumatic amputation of an unspecified arm between the elbow and wrist.It indicates that the entire forearm was severed at a point below the elbow but above the wrist.The laterality of the arm (right or left) is not specified. The “sequela” designation signifies that this code should be used for encounters after the initial amputation injury has healed, to document the long-term effects or complications resulting from the amputation.
Example 1: A patient presents with phantom limb pain several months after a complete traumatic amputation of their forearm following a car accident. The amputation was between the elbow and wrist, and the affected arm (right or left) isn't specified in the current encounter documentation., A patient who experienced a traumatic amputation of the forearm (between elbow and wrist) due to a machinery accident years ago now presents with chronic neuroma pain at the amputation site., A patient who had a complete traumatic amputation of their forearm between the elbow and wrist presents for fitting and adjustment of a prosthetic limb several months post-amputation.
Documentation should include details of the original injury and amputation, laterality of the affected limb, the specific long-term effects or complications the patient is experiencing as a result of the amputation, and any treatment being provided for these complications.
** This code is exempt from the Present on Admission (POA) reporting requirement.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Physical Medicine and Rehabilitation, Pain Management
- Place of Service: Office, Outpatient Hospital, Physical Therapy Clinic