0LPY07Z
Removal Lower Tendon to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | L Tendons |
| Operation | P Removal |
| Body Part | Y Lower Tendon |
| Approach | 0 Open |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
This family covers procedures that take out a device previously placed in or on a tendon, without putting in a new one to replace it. Common examples include removing a suture anchor, internal fixation hardware, or a synthetic patch that was used during an earlier tendon repair. A surgeon might remove such a device because it has served its purpose and healing is complete, because it is causing irritation or a foreign-body reaction, because it has migrated out of position, or because it has become infected.
Patients typically encounter this procedure as a planned second step after an earlier tendon repair or reconstruction, though it can also happen urgently if hardware is causing pain, swelling, or a mechanical problem such as catching or reduced range of motion. Recovery afterward depends heavily on why the device was removed and how much tendon tissue was disturbed getting it out.
Anatomy & Axis Detail
Lower Tendon
Lower tendon, as a body part value, refers to tendon material removed from the trunk or lower extremities when what is being taken out is something previously placed or foreign rather than diseased native tissue-examples include withdrawing a failed hamstring or Achilles tendon graft, extracting a suture anchor or fixation device embedded in tendon, or removing an infected allograft. It is used instead of excision when the object being removed is not part of the patient's own diseased tendon undergoing resection. Because this classification spans many tendons throughout the lower body rather than a single named structure, precise operative documentation of the material removed, its original purpose, and the reason for removal, whether mechanical failure, infection, or rejection, is necessary to support correct coding of the procedure.
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
A code from this family requires documentation that a device, not native or grafted tendon tissue, was the object being taken out. The operative note should name the device (anchor, screw, mesh, tape, etc.) and confirm no replacement device was implanted in the same tendon during the same encounter, since implanting a new device changes the root operation to Replacement or a device-oriented code elsewhere. Coders should also confirm the device sits in the tendon body system rather than in an adjacent joint or bone, since hardware spanning structures is coded to the primary body part addressed.
A frequent error is defaulting to Removal whenever hardware is mentioned, without checking whether the surgeon actually extracted it versus simply inspecting or adjusting it, which would not qualify as Removal.