2025 ICD-10-CM code Z89.21
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Acquired absence of limb Factors influencing health status and contact with health services (Z00-Z99) Feed
Acquired absence of the upper limb below the elbow.
Modifiers may be applicable depending on the circumstances of the visit and procedures performed. Consult the appropriate coding guidelines and payer specific instructions.
Medical necessity for coding Z89.21 is established by the presence of an acquired absence of the upper limb below the elbow. This necessitates follow-up care, prosthetic fitting, rehabilitation services, or management of complications.
The clinical responsibility involves documenting the reason for the limb absence (e.g., trauma, surgical amputation), the date of the event, and any associated complications or rehabilitation needs.The physician should also document the patient's functional limitations and the need for any assistive devices or therapies.
- Factors influencing health status and contact with health services (Z00-Z99)
- Z89.21 is a more specific code under the broader category Z89 (Acquired absence of limb).
In simple words: This code is used when someone is missing their arm below the elbow.The missing arm is not something they were born with, but happened later in life due to an accident, surgery or other cause.
This ICD-10-CM code classifies the acquired absence of an upper limb below the elbow.This indicates a missing upper limb, specifically below the elbow joint, resulting from an event such as an amputation, trauma, or surgical procedure. It does not encompass congenital limb absence.
Example 1: A patient presents for a routine check-up following a traumatic amputation of their right arm below the elbow sustained in a motorcycle accident six months prior. The physician assesses the healing process, assesses prosthetic fit and function, and addresses any ongoing pain or other complications., A patient has a surgical amputation of their left arm below the elbow due to a severe infection that could not be treated with other means.The patient is coded with Z89.21 for the visit during which the surgery was performed.A separate procedure code would also be used for the amputation procedure., A patient who experienced an above-elbow amputation years ago, now presents for prosthetic fitting and adjustments and a follow-up examination for the residual limb. The Z89.21 code would not be appropriate if the original amputation was above the elbow; another Z code would be used in this case.
Complete documentation should include the date and cause of limb loss (e.g., traumatic injury, surgical amputation, congenital), any relevant images or surgical reports, the patient's current functional status, prosthetic use (if applicable), and any associated complications (e.g., phantom limb pain, infection).
** Z89.21 is specific to acquired limb loss below the elbow.Congenital absence of a limb is coded differently. Always ensure appropriate laterality (right or left) is specified if known.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Specialties:Orthopedics, Physical Medicine and Rehabilitation, Prosthetics and Orthotics
- Place of Service:Office, Hospital (Inpatient or Outpatient), Rehabilitation Center,Prosthetics Clinic