0KQ53ZZ
Repair Shoulder Muscle, Right to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | K Muscles |
| Operation | Q Repair |
| Body Part | 5 Shoulder Muscle, 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 muscle tissue when no more specific root operation, such as resection or transfer, applies. Muscles throughout the body, from the biceps and quadriceps to the diaphragm and abdominal wall, can be torn, lacerated, ruptured, or weakened by trauma, disease, or prior surgery, and repair aims to close the defect and restore the muscle's normal structure and, as much as possible, its function.
A surgeon may suture a lacerated muscle after a knife wound, close a traumatic diaphragmatic hernia, or reinforce a weakened abdominal wall following a hernia that isn't addressed with mesh-specific coding. The approach can be open, percutaneous, or via percutaneous endoscopic technique depending on the injury's location and severity.
Because this root operation is a default when nothing else fits, it captures a wide range of everyday muscle-related fixes rather than one narrow procedure type, which is part of why it appears so frequently across trauma and general surgery encounters.
Anatomy & Axis Detail
Shoulder Muscle, Right
The right shoulder muscle group, the deltoid, rotator cuff musculature, and surrounding scapular stabilizers, is repaired most often after traumatic tears, stab or gunshot wounds, or dehiscence of a prior surgical closure rather than as an elective rotator cuff reconstruction, which would typically fall under a different root operation if tendon reattachment to bone is the primary goal. This distinction matters because coders must determine whether the operative intent was restoring the muscle to its normal structure or reattaching a tendon, since the two are captured differently. The right shoulder's dominant use in most patients means traumatic muscle disruption here can carry significant functional consequences, so operative notes typically specify which muscle belly or layer, deltoid, supraspinatus, infraspinatus, was directly sutured or reapproximated.
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
Coders assign a Repair code from this family when documentation describes closing, suturing, or otherwise restoring a damaged muscle without a more specific objective like reinforcing with synthetic material, cutting out tissue, or moving a muscle to a new site. The operative note should identify the muscle involved, the nature of the defect (laceration, rupture, dehiscence), and the technique used to close it, since these details drive both the body part and approach characters.
The most common mistake is defaulting to Repair when the documentation actually supports a more specific root operation. A hernia repaired with mesh should usually be coded as Supplement, not Repair, and a muscle flap advanced to cover a defect elsewhere may qualify as Transfer. Coders also miss that Repair is meant to be a last resort, so failing to rule out Resection, Excision, or Reattachment first is a frequent audit finding. Another pitfall is selecting the wrong specific muscle body part when the operative note only describes a general region, requiring a query back to the surgeon.