0XU207Z
Supplement Shoulder Region, Right to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | X Anatomical Regions, Upper Extremities |
| Operation | U Supplement |
| Body Part | 2 Shoulder Region, 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 reinforces and/or augments the function of a portion of a body part
Procedure Overview
Supplement procedures put in biological or synthetic material to reinforce or augment an upper extremity structure that remains in place, rather than replacing it outright. A typical scenario is applying a mesh or patch graft over an area of weakened soft tissue or fascia in the arm to strengthen it, or augmenting a regional defect with additional material while the native anatomy stays where it is.
This approach is chosen when the existing tissue is intact enough to remain functional but needs added support, commonly after trauma, chronic strain, or a structural weakness identified during another procedure. It differs from a from-scratch repair because material is physically added to bolster the area, and it differs from a full swap because nothing is being removed and replaced.
Anatomy & Axis Detail
Shoulder Region, Right
The right shoulder region, encompassing the skin, subcutaneous tissue, and soft tissue envelope surrounding the glenohumeral joint apart from the joint or muscles coded elsewhere, is a Supplement target when autologous tissue, synthetic mesh, or other biologic material is placed to reinforce or physically augment this area without replacing native structures outright. This is typically performed to reinforce a soft tissue defect, support a weakened area after prior surgery, or add structural bulk following trauma or tumor excision in the region overlying the shoulder joint. Because the shoulder bears significant mechanical load during arm movement, supplemental material placed here must integrate with surrounding soft tissue to withstand repetitive motion, and documentation should specify the type of material used, since this determines the device value assigned.
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 documents that graft, mesh, or synthetic material was placed onto or into an existing upper extremity structure purely to reinforce or augment it, with the native tissue left intact, and the documentation should specify the material type and the exact regional location covered. A common error is coding Supplement when the surgeon actually excised damaged tissue first and put in a substitute, which belongs under Replacement instead. Another recurring issue is failing to capture whether the reinforcing material is autologous, nonautologous, or synthetic, since this qualifier changes the specific code and is easy to overlook if the operative note only says "graft placed" without further detail.