0RPJ0J6
Removal Shoulder Joint, Right to Humeral Surface with Synthetic Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | P Removal |
| Body Part | J Shoulder Joint, Right |
| Approach | 0 Open |
| Device | J Synthetic Substitute |
| Qualifier | 6 Humeral 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, Right
The right shoulder joint is the glenohumeral articulation, a highly mobile ball-and-socket joint stabilized by the rotator cuff, labrum, and capsule, and it frequently receives implanted devices such as suture anchors, arthroscopic fixation hardware, or spacers used in staged infection management. Removal refers to extracting one of these previously placed devices without substituting a new one, a scenario distinct from revision arthroplasty where a prosthetic component is exchanged. Because the joint has extensive soft tissue coverage and a large capsule, retrieval of hardware can range from a simple arthroscopic maneuver for a loose anchor to an open procedure for deeper fixation. Documentation should identify the specific device taken out and confirm that no replacement component was implanted in the same operative session.
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: 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: Humeral Surface
Humeral Surface qualifies a shoulder joint replacement procedure by indicating that the component addressed the humeral head side of the joint. It is distinguished from the Glenoid Surface qualifier, which instead denotes the socket-side component, with many procedures involving both surfaces recorded through separate codes or additional qualifiers.
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.