Major osseous defect, right shoulder region

This code signifies a significant structural deficiency in the bone of the right shoulder area. This defect involves a substantial loss of bone tissue, which can result from trauma, infection, tumor resection, or congenital anomalies, impacting the integrity and function of the shoulder joint.

Apply this code when documentation clearly indicates a major osseous defect affecting the right shoulder, such as a large bone void or significant bone loss. Supporting documentation should include imaging reports (X-ray, CT, MRI) detailing the extent and location of the defect, and physician notes describing the severity of bone loss.

• Ensure the documentation specifies "major" or "significant" to differentiate from minor bone irregularities.
• Verify laterality; this code is specific to the right shoulder.
• Code any underlying cause of the defect (e.g., fracture nonunion, osteomyelitis, tumor) as a primary diagnosis if applicable.