0MWX07Z
Revision Upper Bursa and Ligament to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | W Revision |
| Body Part | X Upper Bursa and Ligament |
| Approach | 0 Open |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device
Procedure Overview
This family covers procedures that correct a problem with a device previously placed in or on a bursa or ligament, such as a suture anchor, tendon graft fixation device, or synthetic ligament augmentation that has shifted, loosened, or is otherwise not functioning as intended. Rather than replacing the device outright, the surgeon repositions it, tightens or adjusts hardware, or removes broken pieces and debris while leaving the rest of the construct in place. These situations typically arise after ligament reconstruction surgery, such as an ACL repair using a graft anchored with screws or buttons, or after a bursa-related implant used to manage chronic bursitis.
Patients usually undergo this type of procedure when imaging or symptoms such as instability, pain, or a popping sensation suggest that hardware from an earlier operation has migrated or partially failed. The goal is to salvage the original repair and restore normal joint mechanics without starting over with a completely new reconstruction.
Anatomy & Axis Detail
Upper Bursa and Ligament
The upper bursa and ligament body part groups connective structures of the upper extremities, shoulder girdle, and trunk when a device previously placed to reinforce these tissues needs correction. Revision becomes necessary when a prior repair, graft, or implanted material has failed, shifted, become infected, or otherwise stopped functioning as intended, requiring the surgeon to adjust, reposition, or partially replace the malfunctioning component without performing an entirely new procedure. Because this body part value spans multiple regions rather than a single named ligament, documentation should indicate the general area involved and the nature of the correction performed, such as removing displaced anchors, adjusting graft tension, or addressing a device-related complication.
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
Coders assign a code from this family when the operative note describes correcting the position of an existing device or repairing a malfunctioning component, not simply removing and replacing it with an identical device, which would instead point toward Change or a removal/insertion pair. Supporting documentation should identify the specific device involved, its original location, and the nature of the correction, such as tightening a graft fixation screw or repositioning a migrated anchor. A common assignment error is coding the entire ligament repair as though it were a fresh procedure rather than isolating the revision to the device itself; another is confusing partial hardware removal, which belongs here, with complete device removal followed by a new device, which requires separate root operations.