2025 ICD-10-CM code Z89.41
(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 Chapter 21: Factors influencing health status and contact with health services Feed
Acquired absence of the great toe.
Modifiers may be applicable depending on the circumstances of the encounter and any procedures performed.Consult the appropriate modifier guidelines.
Medical necessity is established by the documentation supporting the cause of the great toe absence.For example, traumatic amputation requires documentation of the injury and the need for amputation.Surgical removal due to complications of diabetes requires documentation of the diabetes and the medical necessity of the toe amputation.
The clinical responsibility lies with the physician who manages the patient's condition related to the missing great toe. This might involve wound care, prosthetic fitting, or managing complications.
- Chapter 21: Factors influencing health status and contact with health services
- Z89.4 Acquired absence of toe(s), foot, and ankle
In simple words: This code is used when someone is missing their big toe because it was removed or lost due to an injury or surgery.It's important to remember that this is different from being born without a big toe.
This code classifies the acquired absence of the great toe.This absence may result from amputation, post-procedural loss, or post-traumatic loss.It is crucial to differentiate this from congenital absence of the great toe (coded elsewhere).
Example 1: A patient presents following a traumatic amputation of their right great toe in a motor vehicle accident.The physician documents the amputation and the need for prosthetic fitting., A patient undergoes a surgical procedure to remove their left great toe due to severe complications from diabetes.Post-operative care and management are documented., A patient with a history of a traumatic amputation of their great toe seeks follow-up care for assessment of prosthetic fit and management of any residual pain or complications.
Complete medical history detailing the cause of the great toe absence (e.g., trauma, surgery),operative reports if applicable,images (x-rays, etc.),notes on prosthetic fitting or any complications,and documentation regarding any related pain management.
** This code is for acquired absence only; congenital absence is coded elsewhere.Remember to always code any related procedures.
- Payment Status: Active
- Modifier TC rule: Not applicable to this diagnosis code.
- Specialties:Podiatry, Orthopedics, Surgery
- Place of Service:Office, Hospital (Inpatient or Outpatient), Ambulatory Surgical Center