2025 ICD-10-CM code S48
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the shoulder and upper arm (S40-S49) Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Traumatic amputation of the shoulder and upper arm.
Modifiers may be applicable depending on the circumstances of the encounter and the services provided. Consult the latest modifier guidelines for details.
Medical necessity is established by the traumatic injury resulting in the amputation.Documentation supporting the injury, extent of damage, and the need for treatment and rehabilitation is crucial.The necessity of surgical intervention, if performed, should also be clearly documented.
The clinical responsibility encompasses the diagnosis, treatment, and management of traumatic amputation of the shoulder and upper arm. This includes initial assessment, imaging studies to determine the extent of injury, hemorrhage control, surgical repair or reimplantation (if feasible), pain management, infection prevention and treatment, and rehabilitation.
- Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the shoulder and upper arm (S40-S49)
In simple words: Traumatic amputation of the shoulder or upper arm means a part or all of the arm has been separated from the body due to an accident or injury. This can cause bleeding, broken bones, cuts, nerve damage, and serious tissue damage. Doctors diagnose this using physical exams and imaging tests like X-rays and CT scans. Treatment might include stopping the bleeding, surgery, pain relievers, antibiotics, and physical therapy.
Traumatic amputation of the shoulder and upper arm refers to the partial or complete separation of the shoulder and upper arm from the trunk due to trauma.This can result in bleeding, fractures, lacerations, nerve injuries, loss of a body part, and significant soft tissue damage. Diagnosis is based on patient history, physical examination, and imaging studies (X-rays, CT, CTA, MRI) to assess the extent of the injury. Treatment may involve hemorrhage control, surgical repair or reimplantation of the amputated part, analgesics for pain management, antibiotics for infection, nonsteroidal anti-inflammatory drugs to reduce swelling, tetanus prophylaxis if indicated, and physical/occupational therapy.
Example 1: A patient presents to the emergency room after a motor vehicle accident with a complete traumatic amputation of their right upper arm. , A construction worker suffers a partial traumatic amputation of their left shoulder during a workplace accident, requiring immediate surgical intervention., A patient is admitted to the hospital following a traumatic event where they sustained an avulsion injury to their right shoulder, resulting in a near-complete traumatic amputation.
Detailed documentation should include the mechanism of injury, the extent of the amputation (complete or partial, level of amputation), associated injuries (fractures, lacerations, nerve damage), imaging findings (X-rays, CT, MRI), surgical procedures performed (if any),medications administered, and the patient's progress during treatment and rehabilitation.
** The seventh character (A, D, or S) must be appended to indicate the encounter (A=initial, D=subsequent, S=sequela).Detailed documentation of the injury and treatment is critical for accurate coding and reimbursement.
- Payment Status: Active
- Specialties:Orthopedic surgery, emergency medicine, trauma surgery, plastic surgery.
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center