0M9200Z
Drainage Shoulder Bursa and Ligament, Left to No Qualifier with Drainage Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | 9 Drainage |
| Body Part | 2 Shoulder Bursa and Ligament, Left |
| Approach | 0 Open |
| Device | 0 Drainage Device |
| Qualifier | Z No Qualifier |
Operation Definition
Taking or letting out fluids and/or gases from a body part
Procedure Overview
Drainage procedures remove fluid or gas that has accumulated within a bursa, most often as a result of inflammation, infection, or trauma. Bursae are small fluid-filled sacs that cushion joints, and when they become irritated or infected they can swell painfully with excess fluid, a condition commonly known as bursitis. Draining the fluid relieves pressure and pain, and in infected cases removes purulent material that antibiotics alone cannot clear.
This can be done with a needle and syringe for straightforward aspiration of a swollen bursa, such as the olecranon bursa at the elbow or the prepatellar bursa at the knee, or through a small incision when the fluid is thicker or infection requires more thorough evacuation.
Drainage is typically a first-line treatment for symptomatic bursitis and is often paired with fluid analysis to identify infection, crystal disease, or bleeding as the underlying cause.
Anatomy & Axis Detail
Shoulder Bursa and Ligament, Left
The left shoulder houses a dense cluster of bursae, most notably the subacromial-subdeltoid bursa, which cushions the rotator cuff tendons as they glide beneath the acromion, along with the coracoclavicular, coracobrachial, and glenohumeral ligaments that stabilize the joint. Fluid collections here typically arise from subacromial bursitis, septic arthritis extending into the bursal sac, or hematoma following trauma or overhead athletic strain. Because the subacromial space is thin and closely applied to the deltoid and cuff, drainage is often performed under image guidance to avoid injuring adjacent tendon fibers. Documentation should specify laterality and, when possible, whether the targeted structure is a discrete bursa versus a ligamentous sheath, since coders distinguish shoulder bursal drainage from procedures on the rotator cuff tendons proper.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Device: Drainage Device
Drainage Device denotes a device such as a tube or catheter left in place to remove fluid, blood, or air from a body part or cavity following a procedure. It is distinguished from Monitoring Device, which senses and records physiologic data rather than evacuating substances from the body.
Coding & Documentation
The operative or procedure note should describe fluid, pus, or blood being taken out of a bursa, with language such as aspiration, needle drainage, or incision and drainage. Coders need to confirm the target is a bursa rather than a joint space, since joint aspiration is coded to a different body system.
A common assignment error is failing to distinguish diagnostic aspiration from therapeutic drainage when both occur in the same encounter, or missing that a device such as a drain was left in place, which affects the approach and device value. Documentation should also specify whether the procedure was open or percutaneous, since this changes the approach character.