Partial traum amp of left shldr/up arm, level unsp, sequela

This code signifies a partial loss of the left shoulder and/or upper arm due to a past traumatic event, where the specific level of the amputation is not documented. It indicates that the patient is now experiencing a long-term complication or residual effect stemming from this previous injury.

Apply this code when documenting a patient presenting with ongoing issues, such as pain, functional limitations, or prosthetic fitting challenges, directly attributable to a previously sustained partial traumatic amputation of the left shoulder and upper arm. This is appropriate when the initial injury occurred in the past and the current encounter addresses a sequela.

• Ensure documentation clearly states the amputation is "partial" and affects the "left shoulder and upper arm."
• Only use the "S" (sequela) seventh character for encounters addressing complications or residual effects of the healed amputation.
• Confirm the level of amputation is indeed "unspecified" in the medical record before assigning this code.