0QPD04Z
Removal Patella, Right to No Qualifier with Internal Fixation Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | Q Lower Bones |
| Operation | P Removal |
| Body Part | D Patella, Right |
| Approach | 0 Open |
| Device | 4 Internal Fixation Device |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
Removal procedures take out a device that was previously placed in or on a lower bone - hardware such as plates, screws, rods, pins, external fixator components, or spacers used in the pelvis, femur, tibia, fibula, patella, or foot bones. These devices are typically inserted to stabilize a fracture, hold a bone graft, or support a joint during healing, and removal happens once that purpose has been served or if the device is causing a problem.
Reasons for removal vary widely. Hardware may simply be scheduled for extraction after a fracture has healed, especially in children whose growing bones can be irritated by permanent implants. In other cases the device is removed because it has become infected, has loosened, is causing pain from irritating overlying soft tissue, or is interfering with a later procedure such as a joint replacement.
Anatomy & Axis Detail
Patella, Right
The right patella is the sesamoid bone embedded within the quadriceps tendon that protects the knee joint and enhances extensor mechanism leverage, and it may carry tension band wires, screws, or cerclage hardware placed to fix a patellar fracture. Removal at this site involves extracting such hardware, often performed once the fracture has healed, when wires or screws become palpable and irritating beneath the thin overlying soft tissue, or when infection develops around the implant. Because the patella sits directly under the skin with minimal soft tissue coverage, retained hardware is a frequent source of symptomatic prominence, making removal a relatively common follow-up procedure. Documentation should confirm laterality and specify the device extracted, distinguishing this clearly from any partial patellectomy, which would be reported under a different root operation.
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: Internal Fixation Device
Internal fixation device is the general value for hardware such as plates, screws, or rods placed within the body to stabilize bone or joint, used when a more specific configuration is not indicated. It stands in contrast to the named subtypes - Rigid Plate, Intramedullary, Sustained Compression, and Intramedullary Limb Lengthening - which specify how the hardware achieves stabilization.
Coding & Documentation
Coders assign Removal when documentation confirms a device is being taken out and not replaced with another device during the same operative episode - if a new device goes in at the same site, the procedure is Change or a combination of Removal and another root operation such as Insertion, not Removal alone. The device type and the specific bone it was removed from both need to be identifiable from the operative note. A common error is coding Removal for hardware that is only being adjusted or repositioned rather than fully extracted, or overlooking that the removal of a device is bundled into a broader procedure when substantial additional work, like bone repair, is performed at the same site.