0PQ60ZZ
Repair Scapula, Left to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | P Upper Bones |
| Operation | Q Repair |
| Body Part | 6 Scapula, Left |
| 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 the bones of the skull, face, ribs, sternum, and upper limbs - the clavicle, scapula, humerus, radius, ulna, and the small bones of the wrist and hand - when a fracture, crack, or other structural defect needs to be fixed but doesn't fit a more specific repair category like reposition or replacement. A surgeon might use this approach for a depressed skull fracture, a cracked sternum, a small chip fracture in a carpal bone, or a rib that needs stabilization after trauma.
The underlying goal is simply to restore the bone to something close to its normal shape and strength, using whatever technique the situation calls for - wiring, plating, bone grafting, or direct suturing of periosteum. It's often the option coders reach for when nothing else in the root operation list quite matches what the operative note describes, since it functions as the default "fix it" category for bones.
Anatomy & Axis Detail
Scapula, Left
The scapula is a flat, triangular bone gliding across the posterior chest wall that anchors the rotator cuff and other muscles responsible for positioning the shoulder. Because thick muscle padding protects it, fractures of the left scapula generally follow high-energy trauma like a direct blow to the back or a fall onto an outstretched arm, and repair is reported when the bone's body, spine, or acromion process is returned to its normal shape and alignment without joint replacement or internal fixation hardware. Since the scapula has several named projections that can be injured independently, the operative note should specify exactly which portion was addressed and whether the glenoid articular surface was involved, as that surface is coded under its own distinct body part value.
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 assigns from this family when the operative note describes correcting a bone defect without moving a displaced fragment back into alignment (that's reposition) or removing and replacing tissue (that's replacement or supplement). Documentation should specify the exact bone and any device or graft material used, since that affects the qualifier and device value. The most common assignment error is defaulting to repair when the surgeon actually performed a reposition of a displaced fracture fragment - the two are frequently confused because both involve fractures. Another frequent mistake is coding repair when a bone graft was used to reinforce rather than restore the bone, which should instead be captured as supplement.