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Z89.412
ICD-10-CM
Left Great Toe Amputation

Find information on Left Great Toe Amputation including diagnosis codes, clinical documentation requirements, ICD-10 codes, medical coding guidelines, postoperative care, amputation levels, and healthcare resources. Learn about proper coding for partial and complete left great toe amputations, complications, and relevant medical terminology for accurate clinical documentation and billing. This resource supports healthcare professionals in ensuring accurate and comprehensive documentation for left great toe amputation cases.

Also known as

Left Hallux Amputation
Left Big Toe Amputation

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of the left great toe.
  • Clinical Signs : Missing left great toe, possible pain, wound, infection, or altered gait.
  • Common Settings : Hospital, outpatient surgery center, wound care clinic.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z89.412 Coding
Z89.4-

Acquired absence of limb

Covers acquired absence of left great toe due to amputation.

Z89.6-

Acquired absence of part of limb

Relates to loss of part of the left great toe if not fully amputated.

T87.6-

Complications of amputation

For complications following left great toe amputation surgery.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the amputation traumatic?

  • Yes

    Initial encounter?

  • No

    Due to peripheral vascular disease?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left great toe amputation
Left foot amputation
Left great toe injury

Documentation Best Practices

Documentation Checklist
  • ICD-10 Z89.414 Left great toe amputation status
  • Confirm laterality: Left great toe
  • Amputation level: Specify partial or complete
  • Cause of amputation: Document underlying condition
  • Post-op complications: If applicable

Coding and Audit Risks

Common Risks
  • Unspecified Level

    Coding lacks specificity regarding the amputation level (e.g., toe, metatarsal, transmetatarsal), impacting reimbursement and data accuracy. Medical coding, CDI, healthcare compliance.

  • Laterality Neglect

    Documentation may omit left side specificity. Accurate laterality is crucial for proper coding, claims processing, and compliance. Medical coding, CDI, left great toe amputation.

  • Underlying Cause Missing

    Failure to document the underlying condition (e.g., diabetes, peripheral vascular disease) necessitating the amputation. Impacts quality reporting and case mix index. Medical coding, CDI, healthcare compliance.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding: Z89.41-, optimize reimbursement.
  • Detailed documentation of amputation level, reason, laterality.
  • Timely post-op care documentation for compliance, infection control.
  • Diabetes coding (E08-E13) when applicable for accurate risk adjustment.
  • Prophylactic measures documented for compliance, prevent complications.

Clinical Decision Support

Checklist
  • Confirm left great toe amputation: clinical findings, imaging
  • Document amputation level, reason, operative details
  • ICD-10 Z89.41_ / ICD-9 V49.75: code verification
  • Check post-op care plan: pain management, PT, wound care
  • Patient education: prosthesis, mobility aids, follow-up

Reimbursement and Quality Metrics

Impact Summary
  • Left Great Toe Amputation reimbursement depends on accurate ICD-10 (Z89.41-, Z89.42-) and CPT (28820-28825) coding, impacting hospital revenue cycle management and clean claim rates.
  • Quality metrics like surgical site infection (SSI) rate, length of stay (LOS), and readmission rates are crucial for Left Great Toe Amputation cases, impacting hospital quality reporting and value-based purchasing.
  • Proper documentation of amputation level and associated comorbidities (diabetes, peripheral artery disease) is essential for appropriate reimbursement and risk adjustment.
  • Timely and accurate coding of Left Great Toe Amputation improves claim processing efficiency, reduces claim denials, and maximizes hospital revenue integrity.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • ICD-10 Z89.414, validate laterality
  • CPT-4 28820, check documentation
  • Document amputation level precisely
  • Query physician for clarity if needed
  • Consider modifiers for revisions

Documentation Templates

Patient presents with left great toe amputation, status post amputation performed on [Date of amputation].  The amputation level is [Specify level of amputation:  e.g., distal phalanx, through metatarsophalangeal joint, transmetatarsal].  Indication for amputation was [Specify reason for amputation: e.g., peripheral artery disease, gangrene, infection, trauma, diabetic foot ulcer].  The surgical site demonstrates [Describe appearance: e.g., well-healing, signs of infection, dehiscence, granulation tissue].  Patient reports [Patient-reported symptoms: e.g., pain level and character, phantom limb pain, numbness, tingling].  Peripheral pulses in the left foot are [Describe pulses: e.g., palpable, diminished, absent].  Capillary refill in the remaining toes is [Describe capillary refill: e.g., brisk, delayed].  Assessment includes left great toe amputation, [Associated diagnoses, e.g., diabetes mellitus, peripheral neuropathy, osteomyelitis].  Plan includes [Plan of care: e.g., wound care with [Specify dressing type], pain management with [Specify medication and dosage],  offloading of the left foot, physical therapy for gait training and prosthetic fitting evaluation, monitoring for signs of infection].  Patient education provided on wound care, pain management, and signs and symptoms of infection.  Follow-up appointment scheduled in [Duration] for continued wound assessment and management.
Left Great Toe Amputation - AI-Powered ICD-10 Documentation