Lower Extremity Amputation (BKA / AKA)
2788027882wRVU: 9.55 — Amputation, leg, through tibia and fibula; open (guillotine) (standalone primary code — NOT an add-on to 27880; use for damage-control guillotine BKA; 9.55 wRVU, 90-day global)27590wRVU: 13.13 — Amputation, thigh, through femur, any level (standalone primary code for definitive AKA; 13.13 wRVU, 90-day global)27592wRVU: 10.71 — Amputation, thigh, through femur; open (guillotine) (standalone primary for guillotine AKA; 10.71 wRVU, 90-day global)
Right [left] lower extremity [critical limb ischemia / gangrene / non-healing wound / necrotizing infection] not amenable to revascularization; [below-knee / above-knee] amputation planned
Same
Right [left] [below-knee (transtibial) / above-knee (transfemoral)] amputation
[Attending name], MD/DO
[Resident/PA name]
General endotracheal [/ spinal]
The patient is a [age]-year-old [male/female] with [critical limb ischemia / non-reconstructible vascular disease / infected gangrene / necrotizing infection] of the right [left] lower extremity not amenable to revascularization, presenting for [below-knee / above-knee] amputation. Vascular surgery evaluated the patient and determined the level of amputation. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The limb demonstrated [gangrene / tissue loss / infection / non-viable tissue] to the level of [toes / midfoot / ankle / calf]. Skin and subcutaneous tissue at the planned amputation level were [viable / well-perfused / consistent with adequate healing potential]. [Pulse oximetry / TcPO2 / skin perfusion pressure] at the planned level was [X] mmHg [suggesting adequate healing potential].
[BELOW-KNEE (TRANSTIBIAL):]
The patient was positioned supine. The right [left] leg was prepped and draped. Anterior and posterior skin flaps were marked [or a long posterior flap was designed]. The anterior flap was created at the planned tibia transection level. The posterior flap was made longer to provide adequate soft tissue coverage.
Skin and subcutaneous tissue were divided with electrocautery. The muscles of the anterior compartment were divided. The tibia was divided with a [Gigli saw / oscillating saw] at the planned level. The fibula was divided [1.5-2 cm proximal to the tibial level] with a [nibbler / oscillating saw] and the cut end was beveled. The posterior compartment muscles (gastrocnemius, soleus) were divided to create the posterior myocutaneous flap. Major vessels (anterior tibial artery, posterior tibial artery, peroneal artery) were doubly ligated and divided. The tibial and peroneal nerves were pulled gently, ligated, and divided proximally to allow the nerve ends to retract from the stump.
The tibial crest was beveled with a rasp. The posterior myofascial flap was brought anteriorly and secured to the anterior fascia with [0-Vicryl] interrupted sutures. Skin was closed with [staples / interrupted nylon]. A [soft dressing / rigid cast / compression wrap] was applied.
[ABOVE-KNEE (TRANSFEMORAL):]
Anterior and posterior skin flaps were created at the planned femoral transection level. Muscles were divided with electrocautery. The femur was divided with an oscillating saw. The superficial femoral artery and deep femoral (profunda femoris) artery were each doubly ligated and divided separately, along with their accompanying veins. The sciatic nerve was ligated and divided to allow proximal retraction. Myodesis was performed by suturing the adductor magnus through drill holes in the lateral femoral cortex under physiological tension (Gottschalk technique), securing the adductor group to the lateral cortex to maintain femoral alignment in adduction [or myoplasty was performed]. Skin closed with staples.
None
Amputated limb sent to pathology [and microbiology for cultures if infected]
[X] mL
None / [JP drain in wound]
The patient tolerated the procedure well and was taken to the PACU in stable condition. Rehabilitation medicine was notified for prosthetic planning.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** lower extremity ***, *** amputation planned
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** [BKA/AKA]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with *** not amenable to revascularization. Level selected based on ***. TcPO2/perfusion at planned level: ***. Consent obtained.
FINDINGS: Tissue viability at planned level: ***. Perfusion: ***.
PROCEDURE:
Supine. *** leg prepped and draped. [Anterior/posterior flaps OR long posterior flap] designed. Skin and fascia divided. Muscles divided. [Tibia divided at *** level, fibula 1.5-2 cm proximal, fibula beveled / Femur divided at *** level]. Vessels doubly ligated and divided [BKA: anterior tibial, posterior tibial, peroneal / AKA: SFA and profunda femoris separately]. [Tibial and peroneal nerves / Sciatic nerve] ligated and divided under traction. [Tibial crest beveled / AKA: adductor myodesis through drill holes in lateral femoral cortex]. Posterior flap brought anteriorly, secured with 0-Vicryl. Skin closed with ***. Dressing applied.
EBL: *** mL
SPECIMENS: Amputated limb to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable. Rehab notified.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Guillotine Amputation (Damage Control)
Given [sepsis / hemodynamic instability / grossly infected limb], an open guillotine amputation was performed as a damage control procedure. The limb was amputated at the planned level with perpendicular division of all soft tissues and bone. Vessels were ligated. The wound was left open and packed. A formal revision with stump closure will be performed at a planned second operation after source control and resuscitation. Bill the initial procedure with 27882 (BKA) or 27592 (AKA); the planned staged closure uses modifier -58.
Charting Tips
- Document the amputation level selection rationale. TcPO2 >30 mmHg or skin perfusion pressure >40 mmHg at the planned level predicts adequate healing. Document any objective perfusion measurements used to guide level selection.
- Document nerve management. Specifically note that the nerves were ligated and divided under traction to allow the cut ends to retract proximally away from the stump. Inadequate nerve retraction leads to neuroma formation and chronic stump pain.
- For AKA, document myodesis technique (drill holes through lateral femoral cortex, adductor magnus sutured under physiological tension) vs. myoplasty. Myodesis preserves femoral alignment and hip abductor function — document which technique was used.
- For diabetic/infected limbs, document cultures sent from the amputated specimen and any intraoperative findings consistent with osteomyelitis. This guides post-operative antibiotic duration and affects whether bone cultures were taken.
Billing Tips
- BKA (transtibial): 27880 (standard definitive BKA, 14.99 wRVU) or 27882 (open/guillotine BKA, 9.55 wRVU). Open guillotine amputations followed by planned delayed closure: bill 27882 for the initial procedure, then use modifier -58 (planned staged procedure) for the subsequent revision/closure (27884 or 27886). Do NOT use modifier -78 for this sequence — -78 is for unplanned return to OR for a complication, not for a planned staged closure.
- AKA (transfemoral): 27590 (standard definitive AKA, 13.13 wRVU) or 27592 (open/guillotine AKA, 10.71 wRVU). Document whether performed as definitive (flap closure) or open/guillotine; planned revision uses modifier -58; unplanned complication-related return uses -78.
- Through-knee amputation: 27598 (10.94 wRVU). Use for true knee disarticulation, not BKA or AKA.
- Foot/midfoot amputations: 28800 (Chopart/midtarsal amputation, eg, Chopart type procedure; 8.57 wRVU), 28805 (transmetatarsal, 12.39 wRVU). CPT 28800 descriptor is 'midtarsal (eg, Chopart type)' — by coding convention it also covers Lisfranc-level amputations, but the primary anatomic reference is midtarsal/Chopart. Document the specific level of transaction.
- Revision/re-amputation: 27884 (8.54 wRVU) and 27886 (9.77 wRVU) cover revision of a prior amputation stump. 27594 (7.11 wRVU) and 27596 (11.01 wRVU) are revision codes for AKA stumps. Document the prior level and reason for revision (wound failure, infection, bone overgrowth).
- Global period is 90 days for all amputation codes. Post-op wound care and stump revision within the global use modifier -58 when planned or -78 when for unplanned complication. Rehabilitation referral is bundled.
- Document indication (CLTI, infection, trauma), level selection rationale, tissue viability assessment (TcPO2 >30 mmHg or skin perfusion pressure >40 mmHg predicts healing), bone level (cm from joint), and method of flap closure. All affect DRG grouping and quality metric reporting.
General coding reference. Verify with your institution’s billing department before submitting claims.