0RP307Z
Removal Cervical Vertebral Disc to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | P Removal |
| Body Part | 3 Cervical Vertebral Disc |
| Approach | 0 Open |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
Removal procedures on the upper joints take out a device that was previously placed in the joint during an earlier operation, without putting anything else in its place. This covers situations like extracting hardware such as pins, screws, or wires used for a prior fracture repair once the bone has healed, removing an infected or loosened joint spacer, or taking out sutures, anchors, or other fixation devices that are no longer needed or are causing problems.
These procedures are performed when a device has served its purpose, has failed, is causing pain or irritation, or has become infected and needs to come out before any further treatment can proceed.
Anatomy & Axis Detail
Cervical Vertebral Disc
The cervical vertebral disc is the fibrocartilaginous cushion between adjacent cervical vertebral bodies that absorbs axial load and permits the flexibility of the neck, and it is a frequent site for artificial disc replacement or interbody spacer placement when degenerative disc disease causes pain or nerve compression. Removal at this level applies when a previously implanted device, such as a disc prosthesis, cage, or spacer, is taken out without a new device being put in its place, which may occur due to implant migration, subsidence, infection, or persistent symptoms. Given the disc space's proximity to the spinal cord and exiting nerve roots, this is technically demanding and typically performed through an anterior cervical approach, so the record should confirm the specific disc level treated.
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: Autologous Tissue Substitute
Autologous Tissue Substitute identifies a device value where material harvested from the patient's own body, such as an autograft, is used to replace or reconstruct a body part. Its defining feature is tissue origin from the patient, setting it apart from Nonautologous Tissue Substitute, sourced from a donor or animal, and Synthetic Substitute, made of manufactured material.
Coding & Documentation
Coding this family requires documentation that a device is being taken out and that nothing is being put in its place during the same operative episode - if a new device is implanted after removal, the procedure is coded instead as Replacement or Revision depending on what happened to the joint itself. The device type and its original purpose should be clear in the note to support the correct device value.
A common error is coding Removal for hardware taken out during a revision arthroplasty, when the removal of an old component and insertion of a new one in the same joint at the same session should instead be captured as a single Replacement procedure. Coders also sometimes overlook that removal of a device from a joint accompanied by repair of joint damage caused by that device requires an additional Repair or Revision code for the corrected tissue.