2025 ICD-10-CM code S48.912D
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the shoulder and upper arm Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Complete traumatic amputation of the left shoulder and upper arm, unspecified level, subsequent encounter.
Modifiers may be applicable depending on the specific circumstances of service delivery and the payer's guidelines.Consult payer-specific guidelines for appropriate modifier usage.
Medical necessity is established by the traumatic event leading to the amputation, requiring subsequent care, treatment of complications, pain management, rehabilitation (prosthetic fitting), and infection prevention.
The clinical responsibility involves diagnosing the extent of the injury (including nerve and blood vessel damage), determining the feasibility of reattachment (using tools like the Mangled Extremity Severity Score and imaging), managing pain and bleeding, wound care, possible reimplantation, and providing necessary medications (analgesics, antibiotics, tetanus prophylaxis, NSAIDs).Post-operative care, physical therapy, and infection treatment are also crucial elements.
- 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 removed due to an injury, and this is a visit after the initial injury.
This code signifies a complete traumatic amputation of the left shoulder and upper arm at an unspecified level, documented during a subsequent encounter.The amputation is a result of trauma, and the exact level of the amputation is not specified in the medical record.This code is used for the follow-up visit after the initial injury and amputation.
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 not immediately ascertainable due to the severity of the injury.S48.912D is assigned during a subsequent visit for wound care and follow-up., A patient sustains a complete traumatic amputation of their left shoulder and upper arm during an industrial accident. Following initial emergency care, the patient is seen in an outpatient clinic for ongoing management, pain control, and prosthetic fitting, where S48.912D is assigned., A patient is admitted for a subsequent visit after an initial traumatic amputation of their left shoulder and arm.During this hospital stay, they undergo additional surgery to address complications and manage infection. S48.912D would be used for this hospital stay.
Comprehensive documentation should include the details of the traumatic event, the exact location and extent of the amputation (even if unspecified), images from diagnostic tests (X-rays, CT scans, MRI), assessment of nerve and blood vessel damage, treatment provided, and the patient's response to treatment.Any complications and follow-up plans must also be documented.
** This code is for subsequent encounters after the initial traumatic amputation.The initial encounter would be coded using the appropriate initial encounter code (e.g., S48.912A).
- Payment Status: Active
- Modifier TC rule: Not applicable for this diagnosis code.
- Specialties:Orthopedic Surgery, Trauma Surgery, Plastic Surgery
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center