0MPX3JZ
Removal Upper Bursa and Ligament to No Qualifier with Synthetic Substitute, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | P Removal |
| Body Part | X Upper Bursa and Ligament |
| Approach | 3 Percutaneous |
| Device | J Synthetic Substitute |
| 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 bursa or ligament, such as an anchor, augmentation device, or other nonbiological appliance no longer needed or causing a problem. This is distinct from procedures that address the ligament tissue itself, since the target of the operation is the hardware, not the anatomy.
Devices are removed for several reasons: they may have served their purpose and are no longer needed, they may be causing irritation or pain, or they may have failed or become infected and need to come out before further treatment can proceed. A suture anchor left over from an earlier ligament repair that becomes symptomatic is a typical reason for this kind of procedure.
Removal can be a standalone procedure or can happen as part of a larger operation when a device is being taken out and replaced with a new one, in which case both a removal and an insertion may be coded.
Anatomy & Axis Detail
Upper Bursa and Ligament
Removal in this context applies to a device left within a bursa or ligament of the upper extremity, such as a suture anchor, drain, or fixation hardware placed during an earlier repair of the shoulder, elbow, wrist, or hand ligamentous structures. The procedure takes out the foreign material without performing a new repair on the underlying tissue, which distinguishes it from revision or repair procedures at the same site. Indications include hardware that has become symptomatic, a drain no longer needed, or an anchor failing to incorporate properly. Because the upper extremity code aggregates multiple joints rather than specifying one, documentation of the originally implanted device and its location helps confirm this is the correct root operation rather than a repair or revision of the ligament itself.
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.
Coding & Documentation
Documentation should specifically identify the device being taken out and confirm it was previously inserted into the bursa or ligament, rather than being a graft or biological material. The record should describe the reason for removal when available, such as symptomatic hardware, infection, or planned staged treatment, though the reason itself does not change the code.
The common assignment error is coding Removal when a device is actually being taken out and replaced in the same session, since ICD-10-PCS generally requires coding both the Removal and the new Insertion or Replacement separately rather than combining them into one code. Coders should also confirm the device was truly nonbiological hardware and not confuse this with Extirpation, which applies to taking out solid matter such as blood clots or debris rather than a placed device.