0MQC4ZZ
Repair Upper Spine Bursa and Ligament to No Qualifier with No Device, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | Q Repair |
| Body Part | C Upper Spine Bursa and Ligament |
| 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 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
Upper Spine Bursa and Ligament
The upper spine bursa and ligament body part refers to the ligamentous supports of the cervical and upper thoracic vertebral column, including structures such as the anterior and posterior longitudinal ligaments and ligamentum flavum at these levels, which maintain segmental alignment while permitting the neck's wide range of motion. Repair is performed when trauma, degenerative laxity, or intraoperative injury during spinal surgery compromises these supports and threatens stability or neural protection, and the procedure typically involves direct suture reapproximation rather than removal or reconstruction. Given the proximity of the spinal cord and nerve roots, documentation should reflect the precise vertebral level and ligament involved, and repair here is distinct from more extensive stabilization procedures such as fusion.
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
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.