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Z89.421
ICD-10-CM
Right Toe Amputation

Find comprehensive information on Right Toe Amputation diagnosis, including clinical documentation, ICD-10 codes (Z89.41_, Z89.411, Z89.412, Z89.413, Z89.414, Z89.415, Z89.418, Z89.419), medical coding guidelines, healthcare resources, and post-operative care for patients with acquired absence of right toe. Learn about amputation levels, partial toe amputation, complete toe amputation, and related healthcare terminology. This resource supports medical professionals in accurate diagnosis coding and patient care management related to right toe amputation.

Also known as

Amputation of Right Toe
Right Toe Removal

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of all or part of the right toe.
  • Clinical Signs : Missing toe, pain, swelling, infection, difficulty walking.
  • Common Settings : Hospital, outpatient surgery center, wound care clinic.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z89.421 Coding
Z89.4-

Acquired absence of right toe

Codes for acquired absence of right toe due to amputation or other causes.

Z89.6-

Acquired absence of limb

This range covers acquired absence of limbs, including toes, due to amputation.

S98.-

Injury of toe(s)

This code range may be used for the initial injury leading to amputation.

Code-Specific Guidance

Decision Tree for

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

Is the amputation traumatic?

  • Yes

    Level of amputation?

  • No

    Cause of amputation?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right toe amputation
Right foot amputation
Right toe injury

Documentation Best Practices

Documentation Checklist
  • ICD-10 Z89.611 Right toe amputation status
  • Confirm laterality: Right toe amputation
  • Amputation level, partial or complete
  • Cause of amputation (trauma, disease)
  • Post-op complications if applicable

Coding and Audit Risks

Common Risks
  • Laterality Unspecified

    Coding lacks right or left designation leading to claim rejection or inaccurate data reporting. CDI crucial for clarification.

  • Partial vs. Complete

    Imprecise documentation of amputation level (toe, ray, transmetatarsal) causing coding errors and affecting reimbursement.

  • Underlying Cause Missing

    Failure to code the etiology (diabetes, trauma, etc.) impacts quality reporting and case mix index. Requires CDI query.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding: Z89.61, specific laterality code
  • Detailed documentation: Amputation level, reason, comorbidities
  • Timely postoperative care notes: Wound healing, pain management
  • Prophylactic measures: Infection prevention, phantom limb pain control
  • Coding compliance review: Ensure accurate billing and reimbursement

Clinical Decision Support

Checklist
  • Confirm laterality: Right toe documented
  • Amputation level specified (e.g., toe, ray, partial)
  • ICD-10 code Z89.61- present in record
  • Operative report reviewed, matches amputation level
  • Patient education on post-op care documented

Reimbursement and Quality Metrics

Impact Summary
  • Right Toe Amputation reimbursement hinges on accurate ICD-10 coding (e.g., Z89.41-, S00.3-) and CPT coding for surgical procedures, impacting claim denials and revenue cycle.
  • Coding quality directly affects Case Mix Index (CMI) accuracy for hospital reporting, influencing resource allocation and payment.
  • Appropriate POA indicators are crucial for proper MS-DRG assignment and accurate reimbursement for Right Toe Amputation.
  • Timely and accurate coding and documentation improve hospital quality reporting metrics regarding surgical complications and readmissions.

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 specific toe level
  • ICD-10 Z89.4 right toe
  • Document amputation level
  • Consider laterality codes
  • Check 7th character use

Documentation Templates

Patient presents with indication for right toe amputation.  The patient's presenting symptoms include (but are not limited to) right toe pain, infection, gangrene, ulceration, ischemia, or necrosis.  Detailed history taken including onset, duration, and characteristics of symptoms, as well as relevant medical history such as peripheral artery disease (PAD), diabetes, trauma, or other contributing factors.  Physical examination reveals findings consistent with the need for amputation, such as  decreased or absent pulses, diminished sensation, tissue discoloration, or presence of necrotic tissue.  Diagnostic studies, including imaging (X-ray, MRI, CT angiogram) and vascular studies (e.g., Doppler ultrasound, ankle-brachial index ABI), may have been performed to assess the extent of the condition and guide surgical planning.  The risks and benefits of right toe amputation, including potential complications such as infection, delayed healing, phantom limb pain, and the need for revision surgery, were discussed with the patient.  The patient demonstrates understanding and provides informed consent for the procedure.  A plan for right toe amputation, specifying the level of amputation (e.g., partial toe, disarticulation at the metatarsophalangeal joint) and type of anesthesia, has been established.  Post-operative care, including pain management, wound care, and rehabilitation including physical therapy and possible prosthetic fitting, will be addressed.  ICD-10 codes for right toe amputation (e.g., 8D10, 8D11) and CPT codes for the surgical procedure will be utilized for billing and coding purposes.  This documentation supports the medical necessity of the procedure and facilitates accurate clinical documentation for right toe amputation.