0RP103Z
Removal Cervical Vertebral Joint to No Qualifier with Infusion Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | P Removal |
| Body Part | 1 Cervical Vertebral Joint |
| Approach | 0 Open |
| Device | 3 Infusion Device |
| 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 Joint
A cervical vertebral joint refers to the facet articulations connecting adjacent cervical vertebrae, small paired joints that guide neck rotation and lateral bending while sharing load with the vertebral bodies and discs. Devices such as facet screws, interspinous spacers, or components of a posterior fixation construct may be placed at these joints to stabilize a segment affected by degeneration, instability, or prior fracture, and removal is the appropriate root operation when that hardware is extracted without substituting new material. Indications include hardware failure, painful prominence, infection, or confirmed fusion that no longer requires supplemental fixation. Because the cervical spine has multiple mobile segments in close proximity, the operative report should specify the vertebral level so the correct joint is captured.
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: Infusion Device
Infusion Device denotes a device left in place to deliver medication, fluids, or other substances into a body part over time, such as an intrathecal or epidural pump. It is distinct from devices that merely monitor or mechanically support tissue, since its function is ongoing pharmacologic or fluid delivery rather than structural replacement. Common placements include the spinal canal, peritoneal cavity, and vascular access sites.
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.