0SPJ48Z
Removal Tarsal Joint, Left to No Qualifier with Spacer, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | S Lower Joints |
| Operation | P Removal |
| Body Part | J Tarsal Joint, Left |
| Approach | 4 Percutaneous Endoscopic |
| Device | 8 Spacer |
| 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 a lower joint, such as internal fixation hardware, a spacer, drainage tubing, or an external fixator frame. These procedures are performed once the device has served its purpose - for example, after a fracture has healed and screws are no longer needed - or when a device is causing pain, infection, or mechanical irritation and needs to come out. Removal can be a planned, staged part of treatment or an unplanned procedure prompted by a complication.
Because the device itself, not the joint tissue, is the focus, these procedures are typically less extensive than the original surgery that placed the device, though scar tissue and bony ingrowth around older hardware can make removal technically demanding.
Anatomy & Axis Detail
Tarsal Joint, Left
The left tarsal joints, comprising the subtalar, talonavicular, and calcaneocuboid articulations, allow the hindfoot and midfoot to accommodate uneven terrain while transferring weight from the leg to the forefoot. When this joint has previously been stabilized with plates, screws, or staples for arthrodesis or fracture repair, those implants sometimes need to be taken out, which is coded as removal rather than repair since no new tissue is altered. Indications include hardware prominence beneath thin dorsal or lateral skin, painful impingement during hindfoot motion, or infection risk around retained metal. Documentation should specify which tarsal articulation and device were addressed, since the tarsal bones sit close together and imaging reports often name the specific joint the hardware crosses.
Approach: Percutaneous Endoscopic
Percutaneous Endoscopic combines a puncture through skin or mucous membrane with insertion of an endoscope to visualize the procedure internally, as in laparoscopic cholecystectomy. It is distinguished from plain Percutaneous by the presence of scope-guided visualization, and from Via Natural or Artificial Opening Endoscopic by its route being a new puncture rather than an existing orifice or stoma.
Device: Spacer
In Medical and Surgical procedures, a Spacer is a temporary, non-articulating device left in a joint or space after a component is removed, most often an antibiotic-impregnated cement block placed during a staged joint revision to control infection while preserving space and alignment. It is not intended to move like a real joint. It differs from an Articulating Spacer, which is shaped to permit some motion during the interim period, and from a permanent Synthetic Substitute.
Coding & Documentation
The operative note must identify the specific device being taken out and confirm nothing is being put in its place; if a new device replaces the old one, the more specific combination root operation (such as Revision) may apply instead of a plain Removal. The body part coded is the joint from which the device is taken, using the device's original insertion site. A recurring error is coding Removal when hardware is being exchanged for a different device during the same procedure, which should instead be captured as Revision, or when the device is being taken out specifically because it failed, which some coders mistakenly still classify simply as Removal without checking whether Revision criteria are met.