2025 ICD-10-CM code Z89.22
Acquired absence of upper limb above elbow. This code is used to indicate the status of a patient after amputation, post-procedural loss, or post-traumatic loss of an upper limb above the elbow.
Medical necessity for services related to Z89.22 should be supported by documentation of the condition and the need for the specific service provided. For example, if the patient is receiving physical therapy, the documentation should support the need for rehabilitation.
The physician is responsible for documenting the cause of the limb absence and ensuring accurate coding. It's important to differentiate between acquired absence due to trauma, surgical removal, or other reasons, and congenital absence.The physician should also document any functional limitations or related complications.
In simple words: This code indicates that a person is missing an upper limb above the elbow due to an event that happened after birth, such as an accident or surgery.
Acquired absence of upper limb above elbow.This includes disarticulation at the elbow. The code describes a condition where the upper limb is missing above the elbow due to acquired reasons such as amputation or trauma, and not due to a congenital condition. It excludes acquired deformities of limbs (M20-M21) and congenital absence of limbs (Q71-Q73).
Example 1: A patient presents for a follow-up visit after an above-elbow amputation due to complications from diabetes. The code Z89.22 is used to document the acquired absence of the limb., A patient who experienced a traumatic injury resulting in the loss of their upper limb above the elbow is seen for rehabilitation therapy. The code Z89.22 is used to document the current status., A patient who had a previous above-elbow amputation is being fitted for a prosthetic device.Z89.22 is used to indicate the reason for the encounter.
Documentation should clearly specify the level of the amputation (above elbow), the cause (e.g., trauma, surgical removal), the laterality (right or left), any complications, and the patient's current functional status.
** Remember that Z codes are used to document factors influencing health status and contact with health services. These codes should be used in conjunction with procedure codes if a procedure is performed. The code Z89.22 is considered a status code.It should not be used for reporting the acute phase of limb loss.Always ensure accurate laterality documentation to support the use of the appropriate 6th character.
- Specialties:General surgery, Orthopedic surgery, Physical medicine and rehabilitation, Prosthetics and orthotics, Primary care
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office, Rehabilitation Facility