0PQ53ZZ
Repair Scapula, Right to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | P Upper Bones |
| Operation | Q Repair |
| Body Part | 5 Scapula, Right |
| Approach | 3 Percutaneous |
| 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, Right
The scapula is a flat, triangular bone that glides across the posterior chest wall and serves as the origin for the rotator cuff and several other muscles that position and stabilize the shoulder. Because it is well cushioned by surrounding muscle, scapular fractures usually result from high-energy trauma such as a direct blow or fall, and repair on the right side is coded when the bone's body, spine, or acromion is restored to its normal structure without joint replacement or fixation with an internal device meant to hold fragments in position. Given the scapula's several distinct processes, documentation should identify which portion was fractured and whether the glenoid articular surface was involved, since that surface is captured as a separate body part when it is the structure actually repaired.
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.
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.