05QD4ZZ
Repair Cephalic Vein, Right to No Qualifier with No Device, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 5 Upper Veins |
| Operation | Q Repair |
| Body Part | D Cephalic Vein, Right |
| Approach | 4 Percutaneous Endoscopic |
| 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
This family covers surgical repair of the veins that drain the arms, shoulders, chest wall, and skull, including the subclavian, axillary, brachial, basilic, cephalic, hand, azygos, hemiazygos, innominate, and intracranial veins. Repair is used when a vein has been cut, torn, punctured, or has developed a leak or fistula that needs to be closed by suturing or other direct means, and no other, more specific procedure (like replacing the vein with a graft or widening it with a stent) applies. Typical scenarios include a vein injured during trauma, a laceration from a misplaced central line or dialysis catheter, or bleeding discovered during an unrelated operation.
Because these veins carry blood back toward the heart at relatively low pressure, many injuries can be managed with direct suture repair rather than a graft, which is why this family exists as a distinct, catch-all restorative option. Patients undergoing this procedure are typically being treated for an acute injury or a complication of another medical intervention rather than a planned elective condition.
Anatomy & Axis Detail
Cephalic Vein, Right
The right cephalic vein runs along the lateral aspect of the forearm and arm before draining into the axillary vein near the deltopectoral groove, and it is a frequently used site for peripheral intravenous access, blood draws, and pacemaker or defibrillator lead insertion via the cephalic cutdown technique. Repair is typically required after injury during lead placement, catheter insertion, or laceration from trauma, and also to correct stenosis at the site where the vein narrows before joining the axillary vein, a common bottleneck for lead advancement. Its superficial course makes direct surgical exposure straightforward compared to the deeper veins of the upper extremity.
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.
Coding & Documentation
Repair is assigned only when documentation shows the surgeon restored the vein's own tissue to its normal structure - for example, "venorrhaphy," "suture repair of laceration," or "closure of iatrogenic venous injury" - without introducing graft material or performing a more specific root operation. The operative note should identify the exact vein involved (since Upper Veins has separate body part values for each named vessel) and describe the technique used to close the defect.
The most common coding error is defaulting to Repair whenever a vein procedure doesn't obviously fit elsewhere, when in fact a more specific root operation is required if the physician actually excised tissue, controlled bleeding through ligation, or patched the vessel with graft material. Coders also miscode the body part by using a generic "upper vein" value instead of the specific named vessel documented, or they miss that Repair is inappropriate when the vein was ligated and divided rather than reconstructed.