# What ICD9 code would you use?



## rjenn86 (Mar 10, 2014)

I'm needing help regarding an ill fitting prosthesis for ICD9 code? Would I use 996.40??.....Here is the dictation, Thank you : 

Patient presents to the office today with a complaint of an ill fitting the right leg prosthesis status post right below the knee amputation in 2007.  he states that he has had no adjustments to his prosthesis since she was discharged from the hospital following his amputation in 2007.  He has gained significant weight since that time and is having an area of redness on his stump that he and his wife are concerned about.  He is here today for further evaluation.

PHYSICAL EXAMINATION: 
 Patient is alert and oriented x3.  He is in no acute distress.  Moderately obese.  His right leg demonstrates a below the knee amputation with prosthesis currently fitted.  Skin is intact.

ASSESSMENT: 
 Ill fitting prosthesis status post right below the knee amputation

PLAN: 
 Patient is advised that we do not deal with fitting of prostheses, and I have referred him to Evergreen prosthetics and orthotics.  A prescription is sent to Evergreen for repair of the prosthesis.  He will follow up with his primary care provider if any further adjustments need to be done or if he needs any further prescription for a new prosthesis.  The patient and his wife understand and agree with this plan.


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## cling2me2 (Mar 10, 2014)

Rachel,
I would not use 996.40 because category 996.4 is for a Mechanical complication of an INTERNAL device, which the prosthesis is not. Since the physician did not document any pain or skin breakdown, etc, I would use V49.75 = Below the knee amputation influencing health status unless you can ask him to amend his documentation.
Just my opinion.
Tina C., CPC


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## rjenn86 (Mar 10, 2014)

Thank you for your help!


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