G54.6
BillablePhantom limb syndrome with pain
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is G54.6 an HCC code?
Yes. G54.6 maps to Amputation Status, Lower Limb/Amputation Complications under the CMS-HCC V28 risk adjustment model (and Amputation Status, Lower Limb/Amputation Complications under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for G54.6
For G54.6 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed G54.6 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
G54.6 is the ICD-10-CM diagnosis code for phantom limb syndrome with pain. Persistent pain felt in a limb that has been amputated or lost, where the patient feels sensations as if the missing limb is still present. G54.6 sits in the ICD-10-CM chapter for diseases of the nervous system (g00-g99), within the section covering nerve, nerve root and plexus disorders (g50-g59).
Under the CMS-HCC V28 risk adjustment model, G54.6 maps to Amputation Status, Lower Limb/Amputation Complications (HCC 409) with a community, non-dual, aged base RAF weight of 0.350. The V24 model used during the PY2024–PY2025 transition mapped G54.6 the same way and at the same RAF weight. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Specify which limb is affected and laterality. Because G54.6 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for G54.6 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Specify which limb is affected and laterality
- •Document whether pain is the primary complaint versus other phantom sensations
Clinical Significance
Phantom limb syndrome with pain is a complex neuropathic condition where patients experience painful sensations perceived as coming from an amputated or missing limb. This condition affects 50-80% of amputees and significantly impacts rehabilitation, prosthetic use, and quality of life. It maps to CMS-HCC V28 category 409 and V24 category 189, both carrying a RAF weight of 0.350, making it a significant risk adjustment diagnosis.
Documentation Requirements
- ✓History of limb amputation or congenital limb absence documented
- ✓Description of phantom pain: type (burning, shooting, cramping, crushing), location within phantom limb, intensity
- ✓Pain frequency and duration (episodic vs. constant)
- ✓Distinction from residual limb (stump) pain which is a different condition
- ✓Functional impact: effect on prosthetic use, sleep, rehabilitation participation
- ✓Current pain management regimen (medications, mirror therapy, TENS, nerve blocks)
- ✓Assessment of pain severity using validated scale