March 20, 2025
By: Brionna Benedetti, CPC, CRC
Download the full guide: Transplants and Amputations Coding Guide
Lizard Tails
Fun fact: Animals, such as salamanders, frog tadpoles, fish and lizards can regenerate entire appendages as part of an evolutionary survival mechanism. To regrow their appendages, lizards in a particular turn on over 300 genes to regenerate the tail alone and will take more than 60 days to regenerate their tails (1). But wait, why would I mention lizards when I am clearly speaking on transplants and amputations? Is that some sort of messed up joke? Hang in there, there is a point to this analogy.
Why Does it Matter?
Centers for Medicare & Medicaid Services (CMS) “wipes the slate clean” for all patients RAF scores January 1st of every calendar year. The diseases that get “wiped clean” at the beginning of the year also include amputations, transplants, and status codes- leading to these conditions sometimes being missed in the yearly recapture process. We all know that humans are not as fortunate as lizards to be able to regenerate our limbs, though science is getting closer to discovering the mysteries of gene activation for limb regeneration. Until then, once a transplant or amputation is performed, we know that limb or organ will not grow back… but CMS begs to differ. While logically we know the status has not changed from December to January, it is important to recapture these codes at least once in a calendar year to ensure that CMS properly accounts for that patients’ lost appendage, so take off those socks and shoes!
See the difference that good coding practices make in the following example:
A 67-year-old non-disabled, aged into Medicare, male presents for follow up on diabetes, hypertension, and COPD.
| ICD 10 Code | Code Description | HCC Weight V28 Model |
| J44.9 | Chronic Obstructive Pulmonary Disease | 0.319 |
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy | 0.166 |
| I10 | Essential hypertension | 0.00 |
| Not Coded | Chronic diastolic congestive heart failure | — |
| Not Coded | Lung transplant status | — |
| Not Coded | Acquired absence of left great toe | — |
| Z68.41 | BMI 42.2 | 0.186 |
| Not Coded | Morbid obesity | — |
| Demographic Risk Factor: | 0.38 | |
| Total Risk Adjustment Factor (RAF) Score: | 1.051 |
Now take this same 67-year-old non-disabled male patient, but code to the highest level of specificity:
| ICD 10 Code | Code Description | HCC Weight V28 Model |
| J44.9 | Chronic Obstructive Pulmonary Disease | 0.319 |
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy | 0.166 |
| I11.0 | Hypertensive heart disease with heart failure | 0.118 |
| I50.32 | Chronic diastolic congestive heart failure | 0.36 |
| Z94.0 | Lung Transplant Status | 2.531 |
| Z89.412 | Acquired absence of left great toe | 0.598 |
| Z68.41 | BMI 42.2 | — |
| E66.01 | Morbid obesity | 0.186 |
| Demographic Risk Factor: | 0.308 | |
| Diabetes and heart failure comorbidity RAF: | 0.112 | |
| Diabetes and lung disorder comorbidity RAF: | 0.078 | |
| Total Risk Adjustment Factor (RAF) Score: | 4.786 |
This same patients RAF score is almost four times higher when proper coding practices are followed, specifically in coding to the highest level of specificity, reporting conditions that affect patients care, and reporting stable chronic conditions. When coding appropriately, you can see that this patient is much more severe than originally perceived, and that patients’ overall medical spending budget for the year will be increased to be able to accommodate for that patient’s care.
Transplants
Amputations
Documentation and Coding Tips
Do’s ✓
✓ Code transplants and amputations once a year! Take off socks or other coverings and thoroughly inspect the amputation site.
✓ Documentation needs to specify site (foot, ankle, arm, etc.), laterality (left, right, upper, lower), and exact location if more detail is needed (great toe, upper limb above elbow, etc.).
✓ Link the cause/comorbidity of the amputation if know with linking terms “and”, “with”, “due to”, “secondary to” “because of”, etc. and code the primary condition along with the amputation.
✓ If a patient has congestive heart failure and is also status post heart transplant, the patient should be coded as having a complication of the transplanted organ (2).
✓ If a patient has hepatitis and is status post liver transplant, the patient should be coded as a complication of the transplanted organ (2).
✓ If a patient has pneumonia and is status post transplanted lung, this is coded as a complication since this affects the function of the lung. COPD or other non-infections chronic conditions do not apply.
✓ There are no timeframe restrictions on when a complication may occur.
Don’ts ✕
✕ Do not code a transplant status code (Z89.-) if there is an active transplant complication (T86.-). A transplant complication is only coded if the function of the transplanted organ is affected (2).
✕ Do not omit coding CKD for a patient that is status post kidney transplant. Patients may still have some form of CKD even after transplant (2).
✕ Do not code coronary atherosclerosis as a complication of a transplanted heart. This condition does not apply as a complication.
Note: If a transplant is notated and has M.E.A.T (monitor, evaluate, assess/address, test) to support code recapture but has not been re-coded in the calendar year, consider querying the provider.
Sources
- How lizards regenerate their tails… | Arizona State University
- Coding Complications of Transplanted Organs | Health Information Associates
- ICD-10-CM
Find more coding guides at https://chpanetwork.com/guides-tools/.
