0RTJ0ZZ
Resection Shoulder Joint, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | R Upper Joints |
| Operation | T Resection |
| Body Part | J Shoulder Joint, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection of an upper joint refers to the surgical removal of an entire joint structure, such as a joint surface, a disc, or a whole joint component, without replacing it with a prosthetic or graft. This differs from a simple excision because the entire designated body part, not just a portion of it, is taken out. Common reasons for this procedure include severe joint destruction from advanced arthritis, chronic infection that has damaged the joint beyond repair, a tumor involving the joint, or irreparable trauma.
Because the joint is removed entirely rather than reconstructed in the same operation, patients may experience a temporary or permanent change in joint function, and the procedure is sometimes a staged step before a later reconstructive or replacement surgery. In other cases, such as removal of a damaged intervertebral disc component in the upper spine's facet or costovertebral joints, resection relieves pressure on nearby nerves or eliminates a source of chronic pain and instability.
Anatomy & Axis Detail
Shoulder Joint, Right
The right shoulder joint is a highly mobile ball-and-socket articulation between the humeral head and the glenoid fossa of the scapula, dependent on the rotator cuff and glenoid labrum for dynamic stability given its shallow bony socket. Resection of the entire joint is an extensive procedure, generally reserved for overwhelming joint infection unresponsive to lesser treatment, destructive tumor involving the proximal humerus or glenoid, or severe post-traumatic joint destruction, and it typically precedes staged reconstruction or arthroplasty. Because this removes the articulating surfaces without immediate replacement, it differs coding-wise from a joint replacement procedure, and documentation should clearly indicate that resection alone, not simultaneous prosthetic insertion, was performed. The proximity of the brachial plexus and axillary vessels also makes this a technically demanding operation requiring careful surgical exposure.
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 Resection code applies when documentation confirms the entire joint or the entire designated joint component was excised, with no biological or synthetic material put in its place during the same operative episode. Coders need to read closely for language distinguishing a full resection from a partial excision, since Excision is the correct root operation when only part of the joint structure is cut out. If a replacement device or graft is inserted in the same operative session, the case may require an additional Replacement or Supplement code rather than being reported as a stand-alone Resection. A frequent error is assigning Resection when the surgeon actually performed a synovectomy or debridement limited to soft tissue lining the joint rather than removal of the joint structure itself, which belongs to Excision instead.