0RPK3J7
Removal Shoulder Joint, Left to Glenoid Surface with Synthetic Substitute, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | P Removal |
| Body Part | K Shoulder Joint, Left |
| Approach | 3 Percutaneous |
| Device | J Synthetic Substitute |
| Qualifier | 7 Glenoid Surface |
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
Shoulder Joint, Left
The left shoulder joint, the glenohumeral articulation, is a shallow ball-and-socket joint dependent on the labrum, capsule, and rotator cuff for stability, and it is a common site for implanted suture anchors, fixation screws, or temporary antibiotic spacers placed during staged treatment of infection or instability. Removal describes extracting such a device once it has served its purpose, without inserting a replacement, distinguishing this from arthroplasty revision. Given the joint's wide range of motion and dependence on soft tissue tensioning, surgeons must ensure that hardware extraction does not destabilize the surrounding capsule or cuff repair. Accurate documentation of the device type and confirmation that no new implant was placed helps differentiate this procedure from a concurrent repair or reconstruction.
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.
Device: Synthetic Substitute
Synthetic Substitute designates a device made from manufactured, non-biologic material, such as mesh or prosthetic components, used to replace or augment a body part. It is distinguished from the two tissue substitute categories by its artificial composition, which carries different considerations for integration and long-term durability than biologic grafts.
Qualifier: Glenoid Surface
Glenoid Surface qualifies a shoulder joint replacement procedure by indicating that the component addressed the glenoid, the shallow socket of the scapula that articulates with the humeral head. It contrasts with the Humeral Surface qualifier, which denotes the ball-side component of the same joint replacement.
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.