2025 ICD-10-CM code S48.912A
(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 left shoulder and upper arm, unspecified level, initial encounter.
Modifiers may be applicable depending on the circumstances of the service. Consult the official guidelines for appropriate modifier use.
Medical necessity for treatment would be established by the severity of the injury, potential for complications (infection, hemorrhage), and the need for pain management and rehabilitation.The documentation should clearly justify the need for all services rendered.
The clinical responsibility involves diagnosing the injury through patient history, physical examination, and imaging (X-rays, CT, MRI).Treatment may include hemorrhage control, wound cleaning and repair, potential reimplantation, pain management (analgesics, NSAIDs), antibiotic administration, tetanus prophylaxis, and physical/occupational therapy.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S40-S49 (Injuries to the shoulder and upper arm)
In simple words: This code is used when someone has had their left shoulder and upper arm completely torn or cut off due to an accident.This code is only used for the first time the patient is seen by a doctor for this injury.
This code signifies the complete, traumatic removal of the left shoulder and upper arm at an unspecified level during the initial encounter with the patient.The amputation is due to trauma, and the precise level of the amputation is not specified in the documentation. This code is for the first instance of care for this injury. Subsequent encounters would require a different code (S48.912D).
Example 1: A patient presents to the emergency department after a motor vehicle accident with a complete traumatic amputation of their left shoulder and upper arm. The exact level of amputation is unclear due to the severity of the trauma., A construction worker suffers a traumatic amputation of their left shoulder and upper arm while operating heavy machinery. The attending physician documents the injury as a complete traumatic amputation at an unspecified level., A patient is admitted to the hospital following a workplace accident resulting in a complete traumatic amputation of their left shoulder and upper arm. The injury requires immediate surgical intervention, pain management, and infection control.
Detailed description of the injury mechanism, including the type of trauma.Precise location of the amputation (if possible),Imaging reports (X-rays, CT, MRI).Documentation of surgical intervention, if any.Pain management strategies and medication administered.Antibiotic administration records.Physical therapy and rehabilitation plan.Mangled Extremity Severity Score if applicable.
** This code is specifically for the initial encounter; subsequent encounters require a different code (S48.912D).The unspecified level necessitates careful documentation to justify the choice of this code over more specific amputation codes.
- Payment Status: Active
- Modifier TC rule: Not applicable
- Specialties:Emergency Medicine, Orthopedic Surgery, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center