2025 ICD-10-CM code S48.922A
(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
Partial traumatic amputation of the left shoulder and upper arm at an unspecified level, initial encounter.
Modifiers may apply depending on the circumstances and specific services provided (e.g., anesthesia, surgical assistance). Consult appropriate coding guidelines and payer requirements.
Medical necessity is established based on the severity of the traumatic injury requiring immediate medical attention, evaluation, and treatment. This includes managing acute pain and bleeding, preventing infection, and evaluating the possibility of reattachment or reconstructive surgery.The need for specialized care and rehabilitation would also support the medical necessity.
The clinical responsibility includes diagnosing the injury through patient history, physical examination, and imaging studies. Treatment involves managing pain, bleeding, infection, and potential for reattachment of the amputated part. This may include surgical repair, medication, and physical therapy.
- 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 describes a partial tearing away of the left arm and shoulder due to an accident.Some of the arm is still attached, but a part is missing.The doctor doesn't know exactly where the arm was torn. This code is used for the first visit to the doctor after the injury.
Partial traumatic amputation of the left shoulder and upper arm at an unspecified level refers to the partial removal of the shoulder and limb due to an injury.Part of the arm is torn away, while a portion remains connected to the body through soft tissues, muscle, bone, or tendon. This is due to various traumatic events. The specific level of amputation is not documented; this code applies to the initial encounter.The injury may result in severe pain, bleeding, numbness, and damaged tissues (muscles, bones, tendons, skin). Infection, fracture, laceration, nerve injury, and loss of body part are also potential complications. Diagnosis is based on patient history, physical examination, and imaging (X-rays, CT, MRI) to assess the affected area, including nerves and blood vessels, and determine the possibility of reattachment. Treatment might involve hemorrhage control, wound cleaning and repair, potential reimplantation, analgesics, antibiotics, tetanus prophylaxis, NSAIDs, physical/occupational therapy, and infection management.
Example 1: A patient presents after a car accident with a partially severed left arm near the shoulder.The initial encounter uses this code. Subsequent codes will depend on the level of amputation and further treatment. A secondary code from Chapter 20 would also be used to specify the cause (e.g., motor vehicle accident)., A construction worker suffers a partial arm amputation at the shoulder during work. This code is used for initial encounter.Further codes may reflect subsequent surgeries and rehabilitation. An external cause code should be added (e.g., workplace accident)., A patient is brought to the ER after a severe dog attack which partially tears away the upper arm and shoulder. This code applies to the initial assessment and treatment.Additional codes would be added to address the specific injuries (lacerations, fractures, infections) and the cause (animal bite).
Detailed patient history documenting the mechanism of injury.Physical examination findings including the extent of the amputation, presence of fractures, neurovascular status, and wound assessment.Imaging reports (X-rays, CT scan, MRI) to visualize the injury and assess the viability of the remaining limb.Operative reports, if surgery was performed, including details of the procedure.Progress notes detailing the treatment plan and response to therapy. Documentation of any complications (infection, pain management).
** This code is for partial traumatic amputation.Complete amputations have different codes.Always code to the highest level of specificity possible.Consider using additional codes to fully capture the complexity and extent of the injury and treatment rendered.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Emergency Medicine, Orthopedic Surgery, Plastic Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center