0HQT7ZZ
Repair Breast, Right to No Qualifier with No Device, Via Natural or Artificial Opening Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | Q Repair |
| Body Part | T Breast, Right |
| Approach | 7 Via Natural or Artificial Opening |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Procedure Overview
Repair procedures in the skin and breast are used whenever tissue needs to be restored to its normal structure after an injury or defect, and no other more specific root operation better describes what was done. Typical examples include suturing a skin laceration, closing a surgical wound that reopened, or repairing a breast defect that doesn't require reconstruction with an implant or flap.
This category functions as a default option in ICD-10-PCS: it applies when the objective is simply to put anatomy back together using the body's own tissue, without removing, replacing, or transferring tissue from elsewhere. It is commonly performed after trauma, dehiscence of a prior incision, or as the closing step following removal of a skin lesion when the surgeon simply reapproximates the edges rather than using a graft or flap.
Because Repair is the root operation of last resort, it is used only when the procedure doesn't fit any of the more specific root operations, such as suturing skin edges together rather than transferring a flap of tissue or inserting a graft.
Anatomy & Axis Detail
Breast, Right
The right breast comprises glandular, fibrous, and adipose tissue overlying the pectoral muscles, and its skin and parenchyma may require repair after trauma, incision dehiscence following a prior breast procedure, or laceration from an external injury. Repair is assigned when the objective is straightforward closure or restoration of the breast's structure without removing tissue, augmenting it with an implant, or reconstructing it using flap or graft techniques, which would fall under other root operations. Because the breast contains ducts, glandular lobules, and variable amounts of fat, closure technique may depend on how much of the underlying parenchyma was disrupted. Documentation distinguishing simple wound closure from more extensive reconstructive work is essential, since breast procedures often follow oncologic surgery where multiple root operations may otherwise apply to the same encounter.
Approach: Via Natural or Artificial Opening
Via Natural or Artificial Opening means the instrument reaches the target site by passing through an existing body orifice, such as the mouth or urethra, or a surgically created opening like a stoma, without additional incision or scope guidance. It is distinguished from the Endoscopic variant by the absence of a visualizing scope, and from External by actually traversing into the body through that opening.
Coding & Documentation
Coders should verify from the operative note that the closure was a straightforward reapproximation of tissue and not a more complex reconstruction, since Repair is only assigned when no other root operation applies. Documentation should specify the anatomic site closed and confirm that no graft, flap, or synthetic material was used, since those findings point elsewhere.
The most frequent error is defaulting to Repair too quickly, when the physician actually performed a procedure like a flap transfer that should be captured under Transfer, or a breast reconstruction using a graft that belongs under Replacement or Supplement. Another common mix-up is coding a routine surgical closure at the end of an unrelated procedure, such as the incision closure following an excision, which is not separately coded because it is an integral part of the primary operation rather than a distinct repair.