2025 ICD-10-CM code S48.911S
(Valid) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the shoulder and upper arm 19 Feed
Complete traumatic amputation of the right shoulder and upper arm at an unspecified level, sequela.
Medical necessity for the use of this code is established by the presence of a complete traumatic amputation of the right shoulder and upper arm, along with any associated sequelae, as a direct result of an external cause. Documentation should support the ongoing medical care required to manage the long-term effects of the amputation.
Complete traumatic amputation of the right shoulder and upper arm at an unspecified level may result in severe pain, bleeding, numbness, and severely damaged tissues of the muscles, bones, tendons, and skin, as well as infection, fracture, laceration, nerve injury, and loss of body part. Providers diagnose the condition based on the patient’s history and physical examination to assess the affected area to include nerves and blood vessels and determine the possibility of reattachment of damaged tissue through a Mangled Extremity Severity Score and imaging techniques such as X–rays, computed tomography, or magnetic resonance imaging. Treatment options may include stopping the bleeding, cleaning and repairing the wound, with possible reimplantation of the amputated part; medication such as analgesics, antibiotics, tetanus prophylaxis, and nonsteroidal antiinflammatory drugs; physical and occupational therapy as appropriate, and treatment of any infection.
In simple words: This code describes the long-term effects of a complete amputation of the right shoulder and upper arm resulting from a traumatic injury. The exact location of the amputation on the arm is not specified.
Complete traumatic amputation of the right shoulder and upper arm refers to the complete removal of the shoulder and limb at an unspecified level due to an injury from a variety of traumatic events. This code applies to the sequela, a condition resulting from the initial injury.The provider does not document the specific level of the traumatic amputation.
Example 1: A patient presents with a complete traumatic amputation of the right shoulder and upper arm following a motor vehicle accident. The amputation occurred at an unspecified level between the shoulder joint and the elbow. After initial emergency treatment, this code is used to document the long-term condition during follow-up care., A worker gets their right arm caught in industrial machinery, resulting in a complete traumatic amputation of the shoulder and upper arm. The level of amputation is unspecified. This code is used to document the sequela of the injury after the initial treatment phase., A patient experiences a blast injury, causing a complete traumatic amputation of their right shoulder and upper arm at an unspecified level. Following initial surgery and wound management, this code is used to describe the long-term condition resulting from the injury.
Documentation should include details of the initial injury, the level of amputation (if specified), any surgical interventions performed, and ongoing symptoms or complications related to the amputation.
** This code describes a sequela, meaning a late effect or a condition produced after the acute phase of an injury or illness has terminated.It is important to also code the external cause of the initial injury.
- Specialties:Trauma surgery, Orthopedic surgery, Physical medicine and rehabilitation, Pain management
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office, Rehabilitation Facility