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2025 ICD-10-CM code Z89.6

Acquired absence of leg above knee.

A Z code should not be used as a primary diagnosis if a current, active condition exists. If a procedure is performed, a procedure code must accompany the Z code. The Z code should be used in conjunction with codes for any current medical conditions requiring treatment.

The Z89.6 code is used to document a condition influencing the patient's health status.Medical necessity for services provided relates to the reason for the encounter (e.g., prosthetic fitting, pain management, rehabilitation) and should be documented accordingly.

The provider is responsible for documenting the circumstances leading to the acquired absence of the leg above the knee, differentiating it from a congenital condition or acquired deformity.The etiology and any related conditions should be clearly documented.

In simple words: This code documents the loss of a leg above the knee due to an injury, surgery, or other event after birth.

This code indicates the acquired absence of a leg above the knee, encompassing amputation, post-procedural loss, or post-traumatic loss.It excludes congenital absence (Q71-Q73) and acquired deformities (M20-M21).

Example 1: A patient presents for follow-up care after a traumatic amputation of the left leg above the knee following a motor vehicle accident., A patient with a history of peripheral artery disease and gangrene undergoes a surgical amputation of the right leg above the knee. They are now being seen for rehabilitation., A patient who had a previous above-knee amputation presents for fitting of a new prosthetic leg.

Documentation should clearly state the cause of the amputation (e.g., trauma, vascular disease, infection), the level of the amputation (above the knee), the laterality (right or left), and any current associated problems or complications.

** This code is a Z code, indicating a factor influencing health status and contact with health services.It is not a diagnosis of a disease or injury.If a related active condition or injury is present, the appropriate diagnosis code should be reported as the primary diagnosis.

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