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2025 ICD-10-CM code Z89.20

Acquired absence of an upper limb, unspecified level.

Appropriate documentation is crucial for correct coding.The level of amputation must be documented if specified. This code should be used only when the limb absence is acquired, not congenital.If a procedure is performed, a procedure code must also be used.

Modifiers might be used depending on the circumstances of the visit and procedures performed.Consult the official modifier guidelines for detailed information.

Medical necessity would typically depend on the context of the encounter.For example, medical necessity for a prosthetic fitting would need to be established through documentation of the functional limitations resulting from the absence of the limb.A subsequent follow-up visit would require documentation of an ongoing clinical need.

Documentation of the acquired absence of the upper limb, its impact on the patient's health, and any related procedures or treatments.

IMPORTANT Related codes include Z89.21 (Acquired absence of upper limb below elbow), Z89.22 (Acquired absence of upper limb above elbow), and other codes within the Z89 category specifying different levels or limbs.This code should not be used if the absence is congenital (present at birth); codes from the Q71-Q73 range would be more appropriate in that case.Codes from M20-M21 (acquired deformities of limbs) should also be considered depending on the clinical context.

In simple words: This code is used when someone is missing an upper limb (arm or hand) because it was lost after birth, such as due to an accident or surgery.The exact location of where the limb is missing isn't specified.

This code signifies the acquired absence of an upper limb, where the specific level of amputation (e.g., above or below the elbow) is not specified.The absence is acquired, meaning it occurred after birth, rather than being a congenital condition.This code is used when documenting the reason for an encounter, and should be accompanied by a procedure code if a procedure was performed.

Example 1: A patient presents to the emergency room after a motorcycle accident resulting in the amputation of their left arm.The physician documents the injury and performs surgery.This scenario might use Z89.20 along with procedure codes for the amputation., A patient with a prior arm amputation due to a work-related injury requires prosthetic fitting and adjustment.The visit notes the status of the absence, which is recorded using Z89.20, and codes related to prosthetic care might be used., During a routine physical, a patient discloses a prior upper limb amputation from a childhood accident.While no active treatment is required, Z89.20 is used to document the absence of the limb in the patient's record.

Detailed medical history describing the cause of the limb absence (e.g., trauma, surgery, disease), documentation of the level of amputation (if specified), and any associated procedures or rehabilitation efforts.If applicable, documentation should clearly distinguish this from a congenital absence of the limb. Imaging studies (such as radiographs) may also be required, depending on the reason for the visit.

** Always verify coding with the most recent coding guidelines and payer specific requirements.If the level of amputation is known, a more specific Z89 code should be used.In instances where multiple limb amputations are present, each limb should be coded separately.Consider using additional codes to reflect associated conditions, such as infections, pain management needs, or other complications related to the missing limb.

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