Below-Knee Amputation (BKA)
2788027882wRVU: 9.55 — Amputation, leg, through tibia and fibula; open (guillotine) (standalone primary code, NOT an add-on to 27880; use for a damage-control guillotine BKA; 9.55 wRVU, 90-day global)27884wRVU: 8.54 — Re-amputation / stump revision at the below-knee level (8.54 wRVU, 90-day global)27886wRVU: 9.77 — Re-amputation / stump revision at the below-knee level, complex closure (9.77 wRVU, 90-day global)
Right [left] lower extremity [critical limb ischemia / gangrene / non-healing wound / necrotizing infection] not amenable to revascularization; below-knee amputation planned
Same
Right [left] below-knee (transtibial) amputation
[***, 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 amputation. The level was chosen to preserve the knee where perfusion allowed, balancing healing potential against rehabilitation. 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]. Skin and subcutaneous tissue at the planned transtibial 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].
The patient was positioned supine and the right [left] leg was prepped and draped. A long posterior myocutaneous (Burgess) flap was designed [or equal anterior and posterior skin flaps were marked], with the anterior incision at the planned tibial transection level and the posterior flap extended distally for durable soft tissue coverage.
Skin and subcutaneous tissue were divided with electrocautery and the anterior compartment muscles were divided. The tibia was divided with a [Gigli saw / oscillating saw] at the planned level, and the anterior crest was beveled with a rasp to avoid a prosthetic pressure point. The fibula was divided [1-2 cm proximal to the tibial level] with a [bone cutter / oscillating saw] and its cut end was beveled. The posterior compartment muscles (gastrocnemius, soleus) were divided to raise the posterior myocutaneous flap.
The anterior tibial, posterior tibial, and peroneal vessels were individually doubly ligated and divided. The tibial and peroneal nerves were placed under gentle traction and divided sharply so the cut ends retracted proximally away from the weight-bearing stump; a nerve with a significant accompanying vessel was ligated.
The posterior myofascial flap was brought anteriorly and secured to the anterior fascia with [0-Vicryl] interrupted sutures without tension. The skin was closed with [staples / interrupted nylon], and a [soft dressing / rigid cast / compression wrap] was applied.
None
Amputated below-knee segment sent to pathology [and microbiology for cultures if infected]
[X] mL
None / [JP drain in the deep space]
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 ***, below-knee amputation planned
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** below-knee (transtibial) amputation
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with *** not amenable to revascularization. Level chosen to preserve the knee where perfusion allowed. TcPO2/perfusion at planned level: ***. Consent obtained.
FINDINGS: Tissue viability at planned transtibial level: ***. Perfusion: ***.
PROCEDURE:
Supine. *** leg prepped and draped. [Long posterior myocutaneous (Burgess) flap OR equal anterior/posterior flaps] designed. Skin and fascia divided. Anterior compartment divided. Tibia divided at *** level, anterior crest beveled. Fibula divided 1-2 cm proximal and beveled. Posterior compartment divided to raise the flap. Anterior tibial, posterior tibial, and peroneal vessels doubly ligated and divided. Tibial and peroneal nerves divided sharply under traction (ligate if a significant accompanying vessel). Posterior flap brought anteriorly and secured to the anterior fascia with 0-Vicryl without tension. Skin closed with ***. Dressing applied.
EBL: *** mL
SPECIMENS: Amputated below-knee segment to pathology
COMPLICATIONS: None
DISPOSITION: PACU, stable. Rehab notified.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Guillotine BKA (Damage Control)
Given [sepsis / hemodynamic instability / a grossly infected limb], an open guillotine below-knee amputation was performed for source control. All soft tissue and bone 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 flap closure is planned at a second operation after source control and resuscitation. Bill the initial procedure with 27882; the planned staged closure uses modifier -58.
Charting Tips
- Document the level-selection rationale. TcPO2 >30 mmHg or skin perfusion pressure >40 mmHg at the planned level predicts healing. Preserving the knee roughly halves the energy cost of prosthetic gait compared with a transfemoral level, so a below-knee level is preferred whenever it will heal.
- Document nerve management. Divide the tibial and peroneal nerves sharply under gentle traction so the cut ends retract proximally away from the weight-bearing surface; ligate a nerve only when it carries a significant accompanying vessel. Poor retraction leads to a symptomatic stump neuroma.
- Document the bone work. State the tibial transection level, that the anterior crest was beveled, and that the fibula was divided 1-2 cm proximal to the tibia. An un-beveled crest or a long fibula creates a prosthetic pressure point and risks skin breakdown.
- For a diabetic or infected limb, document cultures sent from the specimen and any findings consistent with osteomyelitis at the transection margin. This guides antibiotic duration and whether a bone-margin culture was taken.
- If perfusion or contamination makes primary closure unsafe, use the guillotine variant and document the plan for staged closure. For a transfemoral amputation, use the Above-Knee Amputation note.
Billing Tips
- Bill 27880 for a standard definitive below-knee (transtibial) amputation with flap closure (14.99 wRVU, 90-day global).
- For an open guillotine BKA done for source control, bill 27882 (9.55 wRVU). The planned staged closure or revision (27884/27886) uses modifier -58, not -78. Reserve -78 for an unplanned return to the OR for a complication.
- Stump revision or re-amputation at the same level bills as 27884 (8.54 wRVU) or 27886 (9.77 wRVU, complex closure). Document the prior level and the reason for revision (wound dehiscence, infection, bone overgrowth).
- The 90-day global covers routine stump care and suture removal. A transfemoral conversion for a failed BKA is a new, higher-level procedure (see the Above-Knee Amputation note), not a stump revision.
- Document the indication (CLTI, gangrene, infection, trauma), the level-selection rationale and any perfusion measurement (TcPO2 >30 mmHg or skin perfusion pressure >40 mmHg predicts healing), the bone transection level, and the flap closure method. These affect DRG grouping and quality reporting.
General coding reference. Verify with your institution’s billing department before submitting claims.