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

This code describes the long-term effects or complications arising from a partial traumatic amputation of the shoulder or upper arm, where the specific location and extent of the amputation are not documented. It indicates that the patient is presenting for care related to the residual issues of such an injury, rather than the initial acute event.

This code is appropriate for encounters addressing sequelae of a partial traumatic amputation of the shoulder and upper arm when the original injury occurred in the past and the patient is now being treated for chronic pain, scar tissue, phantom limb sensation, or other late effects. It is used when the documentation does not specify the exact level of the amputation or whether it was the right or left side.

• Always assign this code as a secondary diagnosis, following a code for the specific sequela being treated (e.g., chronic pain, nonunion).
• Ensure documentation clearly indicates a partial amputation and that the encounter is for a late effect ("sequela").
• Avoid using this code for acute injuries; instead, use the appropriate acute traumatic amputation code.