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Repair Lower Extremity Bursa and Ligament, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | Q Repair |
| Body Part | V Lower Extremity Bursa and Ligament, Right |
| Approach | 0 Open |
| 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 a bursa or ligament when it is torn, lacerated, or otherwise damaged but not being replaced with graft material or reinforced with supplemental tissue. Ligaments connect bone to bone and stabilize joints such as the knee, ankle, shoulder, and wrist, while bursae are small fluid-filled sacs that cushion friction points between tendons, bone, and skin. Damage to either structure typically comes from a sudden twisting injury, a fall, overuse, or a laceration, and can leave a joint feeling unstable, painful, or prone to giving way.
The surgeon's goal is to bring the torn edges of the ligament back together, or close and stabilize a ruptured or infected bursa, restoring the structure as close to its original anatomy as the tissue allows. This might mean suturing a partial ligament tear, draining and closing an infected olecranon or prepatellar bursa, or repairing a bursal rupture found during an open procedure. Recovery generally involves bracing or immobilization followed by physical therapy to regain strength and range of motion, and outcomes depend heavily on how completely the native tissue can be restored.
Anatomy & Axis Detail
Lower Extremity Bursa and Ligament, Right
This grouping captures ligaments and bursae of the lower extremity that are not separately identified elsewhere in the body part list, structures such as those stabilizing the hip capsule region or lower leg that fall outside the named knee, ankle, or foot categories. These tissues absorb rotational and shear forces during walking, running, and pivoting, and repair is generally undertaken after a sprain, partial tear, or chronic overuse injury has left the ligament unable to hold the joint in proper alignment, or after a bursa has become symptomatically inflamed. Because this is a catch-all category, precise anatomic naming in the operative note is essential so the right lower extremity procedure is not conflated with a hip, knee, or ankle-specific repair captured under a more specific code.
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.
Coding & Documentation
A coder should look for operative language describing suturing, closure, or reattachment of a bursa or ligament without the use of graft or synthetic material - words like "repaired," "sutured," or "reattached primarily" point here rather than to Replacement or Supplement. The documentation needs to specify which named bursa or ligament was involved and confirm no device or biologic material was left in place to reinforce the structure. A frequent error is coding Repair when the operative note actually describes a mesh or allograft reinforcing the ligament, which belongs under Supplement instead. Another common miss is failing to distinguish a simple bursa drainage (Drainage root operation) from an actual repair of the bursal wall itself.