Above-Knee Amputation (AKA)

CPT 27590 · 13.13 wRVU · 90-day global
CPT27590
wRVU13.13
Global90-day
ApproachOpen
ComplexityComplex
Add-on / Variant CPTs
  • 27592 wRVU: 10.71 — Amputation, thigh, through femur; open (guillotine) (standalone primary code for a damage-control guillotine AKA, NOT an add-on to 27590; 10.71 wRVU, 90-day global)
  • 27594 wRVU: 7.11 — Re-amputation / stump revision at the above-knee level (7.11 wRVU, 90-day global)
  • 27596 wRVU: 11.01 — Re-amputation / stump revision at the above-knee level, complex (11.01 wRVU, 90-day global)
  • 27598 wRVU: 10.94 — Amputation, leg, through knee joint (knee disarticulation, NOT transfemoral; 10.94 wRVU, 90-day global)
Preoperative Diagnosis:

Right [left] lower extremity [critical limb ischemia / gangrene / non-healing wound / necrotizing infection] not amenable to revascularization or below-knee salvage; above-knee amputation planned

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] above-knee (transfemoral) amputation

Attending Surgeon:

[***, MD/DO]

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal [/ spinal]

Indications:

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 [or below-knee salvage], presenting for above-knee amputation. The transfemoral level was selected because [the below-knee tissue was non-viable / perfusion was inadequate for a transtibial level / a prior below-knee amputation failed]. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The limb demonstrated [gangrene / tissue loss / infection / non-viable tissue] extending to [the calf / above the knee]. Skin and soft tissue at the planned femoral level were [viable / well-perfused / consistent with adequate healing potential]. [TcPO2 / skin perfusion pressure] at the planned level was [X] mmHg [suggesting adequate healing potential].

Description of Procedure:

The patient was positioned supine and the right [left] leg was prepped and draped. Equal anterior and posterior fishmouth skin flaps were marked at the planned femoral transection level.

Skin and subcutaneous tissue were divided with electrocautery and the thigh muscles were divided circumferentially down to the femur. The superficial femoral artery and vein and the deep femoral (profunda femoris) vessels were individually identified, doubly ligated, and divided. The sciatic nerve was placed under gentle traction, ligated because it carries a significant accompanying vessel, and divided sharply to allow proximal retraction away from the stump.

The femur was divided with an oscillating saw at the planned level and the cut end was smoothed. Myodesis was performed by securing the adductor magnus through drill holes in the lateral femoral cortex under physiologic tension (Gottschalk technique), holding the femur in adduction to preserve hip abductor function [or a myoplasty was performed by suturing the anterior and posterior muscle groups over the bone end].

The deep tissue was approximated over the femur without tension, the skin flaps were closed with [staples / interrupted nylon], and a [soft dressing / compression wrap] was applied.

Complications:

None

Specimens:

Amputated above-knee segment sent to pathology [and microbiology for cultures if infected]

Estimated Blood Loss:

[X] mL

Drains:

None / [JP drain in the deep space]

Disposition:

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 ***, above-knee amputation planned
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** above-knee (transfemoral) amputation
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***

INDICATIONS: .PTAGE-year-old .PTSEX with *** not amenable to revascularization [or below-knee salvage]. Transfemoral level selected because ***. TcPO2/perfusion at planned level: ***. Consent obtained.

FINDINGS: Tissue viability at planned femoral level: ***. Perfusion: ***.

PROCEDURE:
Supine. *** leg prepped and draped. Equal anterior/posterior fishmouth flaps designed at the planned femoral level. Skin and fascia divided. Thigh muscles divided circumferentially. SFA/vein and profunda femoris vessels individually doubly ligated and divided. Sciatic nerve ligated (significant accompanying vessel) and divided sharply under traction. Femur divided at *** level, end smoothed. [Adductor myodesis through drill holes in the lateral femoral cortex under physiologic tension / myoplasty]. Deep tissue approximated over the femur without tension. Skin closed with ***. Dressing applied.

EBL: *** mL
SPECIMENS: Amputated above-knee segment to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable. Rehab notified.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Open Guillotine AKA (Damage Control)

Given [sepsis / hemodynamic instability / a grossly infected limb], an open guillotine above-knee amputation was performed for source control. All soft tissue and the femur were divided perpendicularly at the planned level without flap creation, the vessels were ligated, and the wound was left open and packed. A formal revision with myodesis and flap closure is planned at a second operation after source control. Bill the initial procedure with 27592; the planned staged closure uses modifier -58.

Charting Tips
  • Document the level-selection rationale, including why a below-knee level was not feasible (non-viable calf tissue, inadequate perfusion, or a failed transtibial amputation). Transfemoral gait roughly doubles the energy cost of a transtibial level, so the note should justify the higher level.
  • Document the closure technique. Myodesis (adductor magnus secured through drill holes in the lateral femoral cortex under physiologic tension) preserves hip adduction and the abductor lever arm; myoplasty approximates muscle over the bone but does not anchor it. State which was used, since it affects prosthetic function.
  • Document nerve and vessel management. Ligate the sciatic nerve before dividing it, since it carries a significant accompanying vessel, and divide it sharply under traction to let it retract away from the stump. Ligate the superficial femoral and profunda femoris vessels separately.
  • For a diabetic or infected limb, document cultures sent from the specimen and any findings consistent with osteomyelitis at the femoral margin. This guides antibiotic duration.
  • For a transtibial amputation, use the Below-Knee Amputation note.
Billing Tips
  • Bill 27590 for a standard definitive above-knee (transfemoral) amputation with flap closure (13.13 wRVU, 90-day global).
  • For an open guillotine AKA done for source control, bill 27592 (10.71 wRVU). The planned staged closure or revision (27594/27596) uses modifier -58; an unplanned return for a complication uses -78.
  • Stump revision or re-amputation at the transfemoral level bills as 27594 (7.11 wRVU) or 27596 (11.01 wRVU, complex). Document the prior level and the reason for revision.
  • A true knee disarticulation bills as 27598 (10.94 wRVU), not 27590. Reserve 27598 for division through the knee joint rather than through the femur.
  • Document the indication (CLTI, gangrene, infection, trauma, failed below-knee amputation), the level-selection rationale, the femoral transection level, whether myodesis or myoplasty was used, and the closure. These affect DRG grouping and quality reporting.

General coding reference. Verify with your institution’s billing department before submitting claims.

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