0RRJ07Z
Replacement Shoulder Joint, Right to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | R Replacement |
| Body Part | J Shoulder Joint, Right |
| Approach | 0 Open |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
Procedure Overview
Replacement procedures on the upper joints put in a device, either biological or synthetic, that physically takes over for all or part of a joint that has been removed or destroyed by disease or injury. Total or partial joint arthroplasty of the shoulder, elbow, or wrist falls into this family, along with implantation of artificial finger or toe joints for severe arthritis. The damaged joint surfaces are taken out and replaced with a manufactured component, or in some cases with donor tissue, that is intended to restore motion and reduce pain long-term.
These procedures are generally reserved for advanced joint disease, such as end-stage osteoarthritis or rheumatoid arthritis, or for joints severely damaged by fracture or avascular necrosis, once nonsurgical treatment has failed to control symptoms.
Anatomy & Axis Detail
Shoulder Joint, Right
The right shoulder joint is the glenohumeral articulation, a ball-and-socket joint whose shallow glenoid and relatively unconstrained capsule allow the greatest range of motion of any joint in the body but leave it vulnerable to instability, rotator cuff-related arthropathy, and osteoarthritis. Replacement is a common and well-established procedure here, ranging from anatomic total shoulder arthroplasty, which resurfaces both the humeral head and glenoid, to reverse total shoulder arthroplasty, which reconfigures the ball-and-socket relationship to compensate for a deficient rotator cuff. Because these approaches use markedly different implant geometries and are chosen based on cuff integrity and glenoid bone stock, documentation should clearly identify whether the procedure was anatomic or reverse, along with the specific components implanted.
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.
Device: Autologous Tissue Substitute
Autologous Tissue Substitute identifies a device value where material harvested from the patient's own body, such as an autograft, is used to replace or reconstruct a body part. Its defining feature is tissue origin from the patient, setting it apart from Nonautologous Tissue Substitute, sourced from a donor or animal, and Synthetic Substitute, made of manufactured material.
Coding & Documentation
Assigning a Replacement code requires documentation that native or previously implanted joint material was taken out and a device was put in to take over its function during the same operative episode - both the removal and the insertion of the new component are captured together under this single root operation rather than as two separate procedures. The specific device, such as a total shoulder prosthesis, reverse shoulder system, or metacarpophalangeal implant, must be documented to select the correct device value.
A common mistake is coding the takedown of the old joint surface as a separate Excision or Removal procedure when it was actually the first step of a Replacement, since PCS treats the entire replace-in-one-session workflow as one code. Coders also need to watch for revision arthroplasty language, which may indicate only certain components were exchanged, still supported under Replacement if a device was both removed and reinserted at that site.