Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated

This code signifies the complete or partial traumatic loss of an arm and hand on one side of the body, where the specific level of the amputation is not documented. It indicates that the amputation is complicated, often due to infection, delayed healing, or foreign body retention.

Apply this code when documentation clearly states a traumatic amputation involving both the arm and hand unilaterally, without specifying the exact anatomical level (e.g., above elbow, below elbow). The "complicated" aspect must be explicitly documented, such as "traumatic amputation with infection" or "traumatic amputation with delayed healing."

• Ensure documentation specifies "traumatic" etiology; otherwise, a non-traumatic amputation code would be more appropriate.
• Verify that both "arm" and "hand" are involved; if only one is mentioned, a more specific code for arm or hand amputation should be used.
• Look for explicit documentation of complications to justify the "complicated" designation; otherwise, an uncomplicated code should be assigned.