2025 ICD-10-CM code Z89.411
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status Chapter 21: Factors Influencing Health Status and Contact with Health Services Feed
Acquired absence of the right great toe.
Modifiers may be applicable depending on the circumstances of the service. Refer to the most current modifier guidelines. For example, a modifier would be used to indicate the place of service, different healthcare providers, or if anesthesia was used during the procedure.
Medical necessity for coding Z89.411 is established through proper documentation of the acquired absence of the right great toe and associated treatment or follow-up care.The reason for the absence should be documented and supported by relevant medical evidence.If the condition affects the patient's daily activities or requires further management, this should be clearly stated in the medical record.
The clinical responsibility associated with this code depends on the context of the patient encounter. It could involve a podiatrist, surgeon (if amputation occurred), or other specialists depending on the underlying reason for the missing toe.Documentation should clearly indicate the reason for the missing toe and any associated treatment or follow-up care.
- Chapter 21: Factors Influencing Health Status and Contact with Health Services
- Z89- Acquired absence of toes
In simple words: This code means the patient is missing their right big toe. This might be because it was amputated, injured, or lost due to another medical reason.The doctor uses this code to show that this missing toe affects the patient's health.
This ICD-10-CM code signifies the acquired absence of the right great toe.This could be due to various reasons including amputation, trauma, or other conditions resulting in the loss of the digit.The code is used to document this condition as a factor influencing the patient's health status, and it may be used in conjunction with other codes that describe the underlying cause or related conditions. A procedure code should accompany this Z code if a procedure was performed.
Example 1: A patient presents following a traumatic injury resulting in the amputation of their right great toe. Z89.411 is used to document the absence of the toe, along with codes describing the injury and the amputation procedure., A patient has a congenital abnormality where their right great toe failed to develop. This is not an acquired absence, so Z89.411 would not be appropriate in this case (Q71-Q73 would be more appropriate). Z codes are for acquired conditions. , A patient is undergoing a routine check-up following a right great toe amputation. Z89.411 is coded along with a Z code for the post-operative follow-up and any relevant procedural codes.
Medical records should include detailed documentation regarding the circumstances surrounding the loss of the right great toe.This includes the date of the event (if an injury or amputation), the method of loss (e.g., trauma, surgery), and any relevant imaging or other diagnostic findings. If the loss is related to a procedure, detailed procedure documentation is mandatory.Detailed history and physical exam should clearly identify the affected toe.
** Z89.411 should only be used when the absence of the right great toe is an acquired condition. If congenital, other codes are required.Always review the complete ICD-10-CM guidelines for the most up-to-date coding conventions.
- Payment Status: Active
- Modifier TC rule: Not applicable to this code.
- Fee Schedule : Not applicable.
- Specialties:Podiatry, Surgery, General Practice
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Ambulatory Surgical Center