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Z89.511
ICD-10-CM
Right Below-Knee Amputation (BKA)

Find comprehensive information on Right Below-Knee Amputation BKA diagnosis, including clinical documentation, medical coding, ICD-10 codes, healthcare procedures, postoperative care, amputation levels, prosthetic management, and rehabilitation. Learn about accurate coding guidelines for Right BKA, amputation complications, and best practices for healthcare professionals involved in the diagnosis and treatment of Right Below-Knee Amputation.

Also known as

Right BKA
Right Leg Amputation Below Knee
right transtibial amputation
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of the leg below the knee joint.
  • Clinical Signs : Absent lower leg, surgical incision site, potential phantom limb pain.
  • Common Settings : Trauma, peripheral vascular disease, diabetes complications, infection.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z89.511 Coding
Z89.41-

Acquired absence of right lower leg

Covers status post right below-knee amputation.

Z89.-

Acquired absence of limbs

Encompasses acquired absence of specified limbs.

S98.-

Other injuries of lower leg

May be used to code complications or sequelae.

Code-Specific Guidance

Decision Tree for

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

Is the amputation traumatic?

  • Yes

    Dominant leg?

  • No

    Due to peripheral vascular disease?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right below-knee amputation
Left below-knee amputation
Right disarticulation of knee

Documentation Best Practices

Documentation Checklist
  • BKA diagnosis: ICD-10 Z89.41, confirm laterality
  • Amputation level: Precise location below knee
  • Reason for amputation: Document underlying cause
  • Surgical technique: Specific procedure details
  • Prosthetic considerations: Initial assessment documented

Mitigation Tips

Best Practices
  • Document BKA laterality, incision site, and residual limb length for accurate ICD-10 coding (Z89.41-)
  • Ensure pre-op imaging, vascular studies, and operative notes support BKA necessity for medical necessity compliance
  • Query physician to specify diabetic, vascular, or traumatic etiology of BKA for optimal DRG assignment & reimbursement
  • Use consistent, specific BKA terminology in clinical documentation to improve data quality and interoperability
  • Address phantom limb pain management in documentation to reflect comprehensive patient care and justify pain codes

Clinical Decision Support

Checklist
  • Confirm documented indication: peripheral vascular disease, trauma, infection, etc.
  • Verify laterality: right below-knee amputation clearly specified.
  • Check imaging/operative reports confirming BKA level.
  • Exclude AKA, through-knee, or other amputation levels.
  • Review documentation for complications: phantom limb pain, infection.

Reimbursement and Quality Metrics

Impact Summary
  • Right Below-Knee Amputation (BKA) Reimbursement and Quality Metrics Impact Summary
  • ICD-10 Z89.41, CPT 27886: Coding accuracy crucial for appropriate BKA reimbursement.
  • Hospital BKA reporting impacts quality scores: surgical site infection (SSI) rates, length of stay.
  • Timely BKA claim submission, accurate coding minimizes denials, optimizes revenue cycle.
  • Prosthetic fitting, rehabilitation crucial for BKA patient outcomes, impacting quality metrics.

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
  • Code Z89.418 for BKA history
  • ICD-10 S88.1xx for traumatic BKA
  • L58.3- for acquired BKA
  • Validate laterality codes
  • Document amputation level clearly

Documentation Templates

Patient presents with a right below-knee amputation (BKA), status post surgical amputation performed on [Date of amputation].  The amputation level is [Specify level, e.g., transtibial, involving which portion of tibia/fibula].  Indication for amputation was [Specific documented medical reason, e.g., peripheral artery disease with critical limb ischemia, non-healing diabetic foot ulcer, traumatic injury, osteomyelitis].  Current symptoms include [List relevant symptoms, e.g., phantom limb pain, residual limb pain, edema, skin breakdown].  The patient's residual limb is [Describe characteristics, e.g., well-healed, erythematous, edematous, presence of drainage, suture/staple status].  Patient is using [Type of pain management, e.g., opioid analgesics, non-opioid analgesics, gabapentinoids].  Prosthetic fitting status is [e.g., not yet fitted, fitted with temporary prosthesis, fitted with definitive prosthesis].  Mobility status is [e.g., ambulatory with assistive device, wheelchair-bound, transferring independently].  Plan includes [Outline plan of care including, e.g., wound care, pain management, physical therapy, occupational therapy, prosthetic referral and training, psychological support, diabetes management if applicable].  ICD-10 code Z89.411 (acquired absence of right lower leg below knee) is applicable.  Follow-up appointment scheduled in [Timeframe] to monitor healing, address pain, and assess progress with rehabilitation.