2025 ICD-10-CM code Z89.4
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status Factors influencing health status and contact with health services Feed
Acquired absence of toe(s), foot, and ankle.
Modifiers may be applicable depending on the circumstances of the visit and any procedures performed.Consult the official coding guidelines for specific modifier application rules.
Medical necessity would be established by appropriate documentation supporting the clinical indication for the encounter, such as follow-up care, prosthetic fitting, or management of complications related to the absence of the limb.
The clinical responsibility would depend on the reason for the encounter. If it's a follow-up after an amputation, the surgeon or orthopedist would be responsible. If for prosthetic fitting, it could be a prosthetist.Other specialties might be involved depending on the cause of the limb loss or any associated complications.
- Factors influencing health status and contact with health services
- Z89.4 is a child code under Z89 (Acquired absence of limb).Further specification is possible with codes such as Z89.41 (Acquired absence of great toe), Z89.42 (Acquired absence of other toes), and so on, providing details about the specific affected area.
In simple words: This code is used when someone is missing a toe, part of their foot, or their entire foot and ankle because of something that happened after they were born (like an accident or surgery).The doctor might use this code if this is the reason for their visit.
This code signifies the acquired absence of one or more toes, the entire foot, or the ankle.The absence is not congenital; it's the result of an event such as trauma, surgery, or other acquired condition.This code is used when this condition is a reason for an encounter with healthcare services, and should be accompanied by a procedure code if applicable.Specific laterality (right or left) and which toes are missing can be further specified using additional codes within the Z89.4 category (e.g., Z89.41, Z89.42 etc.)
Example 1: A patient presents for a follow-up appointment after a below-the-knee amputation. The physician documents the status of the healing process and addresses any concerns.Z89.4 would be used in conjunction with codes describing the surgical procedure. , A patient has lost toes in an accident and needs a consultation regarding prosthetic options.Z89.4 is used to document the reason for the visit to the prosthetist. , A patient had a surgical removal of a portion of their foot due to a tumor. This code would be used in the postoperative visit, along with the appropriate procedure codes and pathology results.
Appropriate documentation should include the details regarding the absence of the toe(s), foot, or ankle, including the reason for the absence (e.g., trauma, surgery, disease).If applicable, this should be supported by imaging studies, pathology reports, operative notes, and medical records related to the event causing the limb loss.Further detail on laterality (right/left) and which toes are missing is helpful for complete coding.
** Z89.4 is a reason for encounter code; it documents the reason for a patient's visit to the healthcare provider.It doesn't describe an active disease or injury but rather a condition that influences the patient's health status and requires medical attention.Always ensure proper documentation exists to support the use of this code, including details on the affected limb and the circumstances of its absence.
- Payment Status: Active
- Specialties:Orthopedics, Podiatry, Surgery, Prosthetics and Orthotics
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center, Other Place of Service (depending on the clinical scenario)