2025 ICD-10-CM code S48.911A
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the shoulder and upper arm (S40-S49) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Complete traumatic amputation of the right shoulder and upper arm, level unspecified, initial encounter.
Modifiers may be applicable depending on the circumstances of the service, for example, place of service or the professional component versus technical component.
Medical necessity is established by the traumatic nature of the amputation.The amputation requires immediate medical attention for hemorrhage control, wound management, surgical intervention (if applicable), pain management, and rehabilitation to minimize long-term disability. This necessitates prompt care and justification of the treatment provided.
The clinical responsibility includes the diagnosis of the injury through patient history, physical exam, and imaging; assessment of the severity of the injury and the feasibility of reattachment;hemostasis (control of bleeding), wound care, surgical repair or amputation, pain management, infection prevention and treatment (antibiotics), tetanus prophylaxis, and post-operative care including pain management, rehabilitation (physical and occupational therapy). The physician should also ensure proper documentation of the injury for billing and legal purposes.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the shoulder and upper arm (S40-S49)
In simple words: This code is for a complete, accidental loss of the right arm from the shoulder up. The doctor doesn't know exactly where the arm was severed. This code is used for the first time the patient is seen after the injury.
This code signifies the complete, traumatic removal of the right shoulder and upper arm at an unspecified level.It's applied during the initial encounter with the patient following the injury. The specific level of amputation is not documented. This code encompasses a range of traumatic occurrences resulting in this type of injury, and may involve significant pain, bleeding, nerve damage, muscle, bone, and tendon injury, skin lacerations, infection, and fracture.Diagnosis relies on patient history, physical examination, imaging studies (X-rays, CT scans, MRI) and potentially a Mangled Extremity Severity Score to assess the possibility of reattachment. Treatment options include hemorrhage control, wound cleaning and repair, potential reimplantation, analgesics, antibiotics, tetanus prophylaxis, NSAIDs, 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 arm at the shoulder. The exact level of amputation is unclear. S48.911A is coded for the initial encounter., During a work-related accident, a construction worker suffers a complete traumatic amputation of their right arm above the elbow due to machinery malfunction.The level of the amputation is not immediately apparent. S48.911A is used to code the initial visit., A patient arrives at the hospital after an explosion, sustaining a complete traumatic amputation of the right upper extremity.The exact site of the amputation requires further evaluation. S48.911A is coded for the initial encounter, with further clarification potentially coded on subsequent visits.
Comprehensive documentation should include details of the mechanism of injury, the exact location of amputation (if possible), details of any accompanying injuries, and the management plan including surgical procedures performed, anesthesia administered, medications prescribed, and rehabilitation plan.
** This code should only be used for initial encounters. For subsequent encounters, use the appropriate codes with 'D' or 'S' suffixes to indicate subsequent or sequelae encounters respectively.
- Payment Status: Active
- Modifier TC rule: The use of TC modifiers would depend on the specific procedures performed and whether separate professional and technical components exist.
- Specialties:Emergency Medicine, Orthopedic Surgery, Trauma Surgery, Plastic Surgery, Rehabilitation Medicine
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center