0LDN0ZZ
Extraction Lower Leg Tendon, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | L Tendons |
| Operation | D Extraction |
| Body Part | N Lower Leg Tendon, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Pulling or stripping out or off all or a portion of a body part by the use of force
Procedure Overview
Tendon extraction procedures involve pulling or stripping out all or part of a tendon using mechanical force, most often to remove a tendon that has become severely diseased, calcified, or is being harvested for use elsewhere in the body. A common example is stripping the long saphenous vein equivalent in tendon work, such as harvesting the palmaris longus or a strip of hamstring tendon to serve as graft material for reconstructing a torn ligament or another damaged tendon. It is also used to remove a tendon that is chronically inflamed or fibrotic and no longer functions, when leaving it in place would cause ongoing pain or restrict motion.
Patients typically encounter this procedure as one step within a larger operation, such as ACL reconstruction using a hamstring autograft, rather than as a standalone treatment. The extracted tendon tissue is either discarded because it is diseased, or preserved and repositioned for grafting, which distinguishes this from a simple excision.
Anatomy & Axis Detail
Lower Leg Tendon, Right
The lower leg tendons include the tibialis anterior, tibialis posterior, and peroneal (fibularis) tendons that travel along the tibia and fibula toward the ankle and foot, transmitting the pull of leg muscles into dorsiflexion, inversion, and eversion. Extraction on the right lower leg tendon typically applies when a surgeon removes ruptured tendon fragments, degenerated or fibrotic tissue, a foreign body, or hematoma from within the tendon or its sheath without cutting the tendon to accomplish the removal. This is common in chronic posterior tibial tendon dysfunction, where frayed intrasubstance tissue is pulled out before any repair or transfer, or after a peroneal tendon tear where loose debris is cleared. Because these tendons run in narrow synovial sheaths, the extracted material is often small in volume but clinically significant for restoring smooth tendon gliding.
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
Coders assign an extraction code from this family when documentation shows tendon tissue being pulled or stripped out by force, commonly during graft harvesting for ligament or tendon reconstruction elsewhere in the body. The operative note must specify that the tendon (not a ligament, muscle, or bursa) was the harvested structure and identify the specific tendon and body part value.
The most frequent assignment error is confusing extraction with excision when a portion of tendon is simply cut away rather than pulled out with force - excision applies when a scalpel or similar sharp method removes the tissue without traction. Coders also sometimes miss that harvested graft tissue used elsewhere still generates a separate code for the extraction site itself, distinct from the code for wherever the graft is placed.