2025 ICD-10-CM code Z89.412
Acquired absence of left great toe.
This code is typically used to indicate a past event that impacts the patient’s current health status. Medical necessity for services related to the missing toe, such as custom footwear or orthotics, may be supported by this code in conjunction with other diagnoses.
Clinicians use this code to document a patient's status post amputation. This information is crucial for a comprehensive understanding of a patient’s medical history. It is also relevant for ordering appropriate footwear or other assistive devices. Proper documentation by the provider is crucial for accurate coding.
In simple words: This code indicates that the patient is missing their left big toe due to a past amputation or other reason.
Acquired absence of left great toe. This code is used to document the status of a patient who has had their left great toe amputated or otherwise lost.It does not describe the amputation procedure itself, but the resulting condition.
Example 1: A patient presents for a routine check-up.During the physical exam, the physician notes the absence of the patient's left great toe due to a previous amputation. The code Z89.412 is used., A patient with diabetes is seen by a podiatrist for a foot exam. The patient has a history of a left great toe amputation. The podiatrist documents this using the code Z89.412., A patient is being fitted for custom orthotics. They are missing their left great toe due to a prior trauma.The orthotist uses Z89.412 to document the missing toe, which informs the design of the orthotic.
The documentation should clearly state the absence of the left great toe and indicate whether it is due to a prior amputation, trauma, or other cause.Ideally, the date or approximate date of the loss of the toe should also be documented. Documentation can appear in various parts of a clinical note such as the history of present illness (HPI), review of systems (ROS), physical examination (PE), or past medical history (PMH).
** This code identifies the status post loss of the left great toe. For billing purposes, it must be accompanied by a procedure code if a procedure is performed during the encounter. The code is also used for tracking and statistical purposes.
- Specialties:Podiatry, Orthopedics, Primary Care, General Surgery, Physical Therapy, Prosthetics/Orthotics
- Place of Service:Office, Inpatient Hospital, On Campus-Outpatient Hospital, Outpatient Hospital,Skilled Nursing Facility, Nursing Facility, Home Health,Other Place of Service.