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2025 ICD-10-CM code S78

Traumatic amputation of the hip and thigh.

Always code to the highest level of specificity. Use additional codes to indicate the cause of injury (Chapter 20), retained foreign bodies (Z18.-), and any complications.

Modifiers may be applicable depending on the specific circumstances of the service provided. Consult the appropriate modifier guidelines.

Medical necessity is established by the nature of the traumatic injury, requiring extensive medical intervention for life-saving measures, pain control, wound management, infection prevention, functional restoration, and emotional support.

The clinical responsibility includes diagnosis based on history, physical examination, and imaging; determining the severity of the injury (e.g., Mangled Extremity Severity Score); managing blood loss; wound care and repair; possible limb reattachment; pain management; infection prevention and treatment; prosthetic fitting (if needed); and providing rehabilitation and mental health support.

IMPORTANT:More specific codes within the S78 range (e.g., S78.0 for amputation at the hip joint) should be used if the level of amputation is known.Secondary codes from Chapter 20 (External causes of morbidity) are required to specify the cause of the injury, unless the external cause is already included in the T-section code.A code from Z18.- (Retained foreign body) should be added if applicable.

In simple words: This code describes the loss of all or part of your upper leg due to an injury like a car accident, a crushing injury, or an explosion.It can cause a lot of pain and bleeding and requires extensive medical care, possibly including surgery, rehabilitation, and mental health support.

Traumatic amputation of the hip and thigh refers to the complete or partial loss of the upper leg due to trauma.This can result from various causes, including accidents (e.g., traffic accidents, crush injuries, explosions), or workplace injuries. The injury may involve significant blood loss, pain, nerve damage, bone fractures, soft tissue damage, blood vessel injury, infection, and the potential for abnormal bone growth (heterotopic ossification) in the remaining bone.Diagnosis involves patient history, physical examination, and imaging studies (X-rays, CT scans, MRI) to assess the extent of the injury. Treatment may include hemorrhage control, wound debridement and repair, possible reattachment of the limb, pain management (narcotics, NSAIDs), antibiotics for infection prevention, tetanus prophylaxis, and prosthetic fitting if reattachment is not feasible. Physical and occupational therapy, and mental health counseling may also be necessary.

Example 1: A patient is involved in a motor vehicle accident resulting in a complete traumatic amputation of their right hip and thigh.The treating physician performs emergency surgery to control bleeding and perform debridement.The limb is not reattachable. The patient is subsequently fitted with a prosthesis and undergoes physical therapy., A worker suffers a crush injury at a construction site, leading to a partial traumatic amputation of their left hip and thigh.Microsurgery is attempted to reattach the partially severed limb, followed by extensive rehabilitation., An explosion results in a complete traumatic amputation of the hip and thigh. The patient requires multiple surgeries, blood transfusions, and long-term rehabilitation. Psychological support is necessary to address the emotional consequences of the injury.

Detailed patient history including mechanism of injury; thorough physical examination findings; results of imaging studies (X-rays, CT scans, MRI); laboratory results (hemoglobin, hematocrit, coagulation studies, blood cultures); operative reports if surgery is performed; details of rehabilitation and prosthetic fitting (if applicable); and any documentation related to mental health services.

** The code S78 encompasses various degrees of traumatic amputation, from partial to complete loss of the upper leg.The level of amputation should be specified if known using additional characters within the code.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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