0LB34ZX
Excision Upper Arm Tendon, Right to Diagnostic with No Device, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | L Tendons |
| Operation | B Excision |
| Body Part | 3 Upper Arm Tendon, Right |
| Approach | 4 Percutaneous Endoscopic |
| Device | Z No Device |
| Qualifier | X Diagnostic |
Operation Definition
Cutting out or off, without replacement, a portion of a body part
Procedure Overview
Tendon excision procedures cut out and remove a portion of a tendon without replacing it, typically to address a tumor, a chronically degenerated segment, a painful nodule, or scar tissue that is limiting motion. A well-known example is excision of a trigger finger nodule or a portion of tendon affected by tenosynovitis that has not responded to more conservative treatment, as well as biopsy of a suspicious mass for diagnostic purposes.
Because only part of the tendon is taken and the remainder is left in place, the surgeon must weigh how much tissue can be safely removed without compromising the tendon's mechanical function. In many cases the excised tissue is sent to pathology, which both confirms the diagnosis and distinguishes this procedure from techniques that simply destroy tissue in place.
Anatomy & Axis Detail
Upper Arm Tendon, Right
Upper arm tendon excision on the right most often involves the distal biceps or triceps tendon, structures that transmit substantial force across the elbow and shoulder and are prone to partial tearing, tendinosis, or entrapment by adjacent bony spurs. Removing a diseased segment is typically performed to relieve pain or prevent progression to complete rupture, and the excised tissue is cut free without replacement, distinguishing it from repair or reattachment procedures. Because the biceps and triceps tendons are long structures spanning much of the upper arm, the operative note should indicate the specific tendon and level of excision, as this affects strength testing and rehabilitation expectations for elbow flexion or extension afterward.
Approach: Percutaneous Endoscopic
Percutaneous Endoscopic combines a puncture through skin or mucous membrane with insertion of an endoscope to visualize the procedure internally, as in laparoscopic cholecystectomy. It is distinguished from plain Percutaneous by the presence of scope-guided visualization, and from Via Natural or Artificial Opening Endoscopic by its route being a new puncture rather than an existing orifice or stoma.
Qualifier: Diagnostic
Applied chiefly to Excision, this qualifier marks that tissue was removed specifically for diagnostic purposes, i.e., a biopsy intended for pathologic evaluation rather than to treat disease. It distinguishes biopsy-type excisions from therapeutic excisions of the same body part, which are coded without this qualifier even though the physical technique may be identical.
Coding & Documentation
A code from this family is appropriate when the operative note documents cutting out and removing a defined portion of tendon tissue, with the remaining tendon left intact and nothing reconstructed at the same time. Look for language describing a specimen sent to pathology, the anatomic tendon and location, and confirmation that the entire tendon was not removed, which would instead point toward Resection.
A common mistake is coding Excision when the whole tendon was actually removed, since ICD-10-PCS distinguishes cutting out "all or a portion" only when characterizing the two operations differently, that is, Excision for a portion and Resection for all of a body part. Coders also sometimes overlook a concurrent repair, such as a tendon graft or suture closure performed after excision, which requires a separate code if it meaningfully restores structure beyond simple wound closure.