October 28, 2025
Accurate and complete medical record documentation helps establish a comprehensive record of your patients’ health status. Documenting the correct diagnostic statement and choosing the correct ICD-10-CM diagnosis code is an important step in the process.
Reporting a previous surgical amputation is often incorrectly reported as a current traumatic amputation. Previous amputations can be correctly reported with a Z-category code for amputation status. It is helpful to have the date or year of the amputation documented in the problem list. Traumatic amputations are reported with an injury code from the appropriate S-category codes, with the correct seventh character for phase of illness. Surgical amputation is reported with a diagnosis code for the condition requiring the amputation.
Examples
| Reason for visit | Diagnostic statement | ICD-10-CM code | |
| Surgical care immediately followinglower-leg traumatic amputation through tibia and fibula | Amputation of lower leg at knee level | S88.112A – Complete traumatic amputation of lower leg at knee level, initial encounter | Add the appropriate seventh character for encounter type to each code from category S88. A – initial D – subsequent S – sequela (use additional external cause codes when applicable) |
| Six-week follow-up for lower-leg tibia/fibia traumatic amputation | Amputation of lower leg at knee level | S88.112D – Complete traumatic amputation of lower leg at knee level, subsequent encounter | |
| Request authorization for prosthetic limb | Amputation status (document level) | Z89.— – Acquired absence (of documented level) | |
| Annual wellness visit assessment of amputation site | Amputation status (document level) | ||
| Use additional status code from category Z97.– for presence of artificial limb when a prosthetic limb is present. | |||
Cigna Healthcare® Medicare Advantage is becoming HealthSpringSM. Our new benefit plans will be rolled out under the HealthSpring name during the 2025 annual enrollment period. Starting in January 2026, you will begin seeing patients with HealthSpring benefit coverage. Learn more.
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