Revenue Cycle Insider

Question: Encounter notes indicate that a patient suffers from “phantom limb syndrome.” I know this has to do with a patient who has lost a limb, but what exactly does the syndrome entail, and how do I choose an ICD-10-CM code for the condition?

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Answer: Phantom limb syndrome (PLS) occurs when a patient who has lost a limb feels pain or other sensations in said lost limb. There are a pair of diagnosis codes you will choose from for PLS.

If the PLS is accompanied by pain, you’ll report G54.6 (Phantom limb syndrome with pain). If the patient complains of aching, burning, itching, numbness, pinching, tingling, stabbing, or throbbing, they are likely a G54.6 patient.

The pain from PLS could manifest itself in countless other ways, though those listed above are some of the more common symptoms. The pain from PLS might be triggered by touch, weather change, or physical/emotional stress.

According to Cleveland Clinic, “Many people report that they feel phantom pain during the first six months after a limb loss. The pain intensity and frequency usually decrease after that. Research shows most people continue to have some phantom pain two years after amputation.” Studies have shown that half of all people who have lost a limb suffer from PLS with pain.

There is a chance, however, that a patient will suffer from PLS without pain. When this occurs, opt for G54.7 (Phantom limb syndrome without pain). In these cases, the patient might feel that the phantom limb is:

• Still attached,
• Situated in an unusual position,
• Moving around, or
• Shrinking.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC