0XB23ZZ
Excision Shoulder Region, Right to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | X Anatomical Regions, Upper Extremities |
| Operation | B Excision |
| Body Part | 2 Shoulder Region, Right |
| Approach | 3 Percutaneous |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, a portion of a body part
Procedure Overview
These codes describe cutting away a portion of tissue from an upper-extremity region - the arm, forearm, wrist, hand, or elbow - without replacing what is removed, when the excised tissue cannot be attributed to one specific structure such as a single muscle or nerve. A typical example is removal of a soft-tissue mass, a chronic ulcer bed, or scar tissue that spans multiple layers of the limb. The goal is usually diagnostic (biopsy of an unexplained lump) or therapeutic (removing diseased or damaged tissue that is limiting function or causing pain).
Because the tissue involved crosses normal anatomical boundaries, surgeons and pathologists often describe the specimen by its location in the limb rather than by a single named organ.
Anatomy & Axis Detail
Shoulder Region, Right
Excision of the right shoulder region removes abnormal tissue from the soft tissue envelope surrounding the glenohumeral joint - skin, subcutaneous fat, muscle, or a discrete mass - without taking the entire anatomic structure, distinguishing it from a formal joint procedure or resection. Typical indications include biopsy or removal of a soft tissue tumor such as a lipoma, excision of a chronically inflamed subacromial bursa, or debridement-adjacent removal of a localized lesion overlying the deltoid. The shoulder's dense concentration of neurovascular structures, including the axillary nerve as it wraps around the surgical neck of the humerus, means the surgeon must work carefully around this region even for superficial excisions. Documentation should specify laterality, the tissue layer or structure excised, and whether margins were taken for a suspected neoplasm, which affects both surgical planning and coding precision.
Approach: Percutaneous
Percutaneous describes entry by needle or instrument puncture through the skin or mucous membrane to reach the site of the procedure, without cutting the tissue open or using a visualizing scope. It differs from Open in that the site itself is never exposed, and from Percutaneous Endoscopic in that no endoscope is used to see internal structures. Common examples include needle biopsies and injections.
Coding & Documentation
Coding from this family requires the pathology or operative note to confirm that only part of the region was removed, not the entire body part, and that the tissue removed does not correspond to a more specific body system value already available in ICD-10-PCS. The qualifier for diagnostic versus therapeutic intent matters and should be pulled directly from the physician's stated purpose. A common mistake is assigning this code when the excision actually involved a single identifiable muscle, tendon, or piece of skin, which belongs in that structure's own body system rather than the general anatomical-regions grouping.