I would appreciate suggestions on how to best code an office visit for a patient who came in to "discuss renewal of prosthesis." The chart states that patient's current prosthesis is worn and in need of replacement. Provider is referring patient to PT for a functional assessment to replace the Left Tibia prosthesis. I am having difficulty in finding a diagnosis code that I could recommend to my provider, he coded S88.119A (Complete traumatic amputation at level between knee and ankle, unspecified lower leg, initial), I know this to be incorrectly used in this situation.
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Wiki Prosthetic Replacement Coding
- Thread starter KathleenJ
- Start date
TThivierge
True Blue
Hi Kathleen 
Your provider must list which leg right or left leg amputated & reason with his or her documentation. but it seems pt needs consultation to another provider(that should be put in notations) Id use as first dx Z01.89 since first listed Z code then list other dx below. CPT code 99212 if check vitals and other chronic illness and CPT 96171 assessment for clinical help. Put illness dx first then Z code last Z13.82 or others listed below. Or just put CPT 96171 as only cpt and dx fit below. Your provider should add who sent to as referral to help pt get new prosthesis in medical record. Was it due to illness, car accident, war ? Locate this external dx and add it to amputation and estimated date of injury. Also I d code it as sequela not current accident.
Z01.89 first listed dx If new pt 99203 96171 or just CPT 96171 alone
S88.111 S traumatic amputation right leg sequala (if it is patient's R leg)
Probably walking difficulties now dx R26.82
T84.218 breakdown of prosthesis if this is the case
Z89.521 Absence of right knee
Z96.651 Right leg Prosthesis
I hope helped you
Lady T
Your provider must list which leg right or left leg amputated & reason with his or her documentation. but it seems pt needs consultation to another provider(that should be put in notations) Id use as first dx Z01.89 since first listed Z code then list other dx below. CPT code 99212 if check vitals and other chronic illness and CPT 96171 assessment for clinical help. Put illness dx first then Z code last Z13.82 or others listed below. Or just put CPT 96171 as only cpt and dx fit below. Your provider should add who sent to as referral to help pt get new prosthesis in medical record. Was it due to illness, car accident, war ? Locate this external dx and add it to amputation and estimated date of injury. Also I d code it as sequela not current accident.
Z01.89 first listed dx If new pt 99203 96171 or just CPT 96171 alone
S88.111 S traumatic amputation right leg sequala (if it is patient's R leg)
Probably walking difficulties now dx R26.82
T84.218 breakdown of prosthesis if this is the case
Z89.521 Absence of right knee
Z96.651 Right leg Prosthesis
I hope helped you
Lady T
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