0LPX00Z
Removal Upper Tendon to No Qualifier with Drainage Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | L Tendons |
| Operation | P Removal |
| Body Part | X Upper Tendon |
| Approach | 0 Open |
| Device | 0 Drainage Device |
| 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
Upper Tendon
The upper tendon body part is used for tendon material taken out of the body from the upper extremities, head, neck, or trunk when the tissue itself-rather than an obstruction within it-is being removed, such as extracting a previously placed tendon graft, an infected segment of tendon, or a foreign device like a suture anchor tunneled through tendon tissue. This is distinct from excision or resection of native diseased tendon, applying instead to material that was placed during a prior procedure or that has become a foreign body requiring extraction. Because the term spans multiple upper body regions rather than one specific tendon, the operative note should clarify what was removed, from where, and why, whether that is a failed graft, hardware, or a device no longer serving its purpose, to support accurate documentation of the removal.
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: Drainage Device
Drainage Device denotes a device such as a tube or catheter left in place to remove fluid, blood, or air from a body part or cavity following a procedure. It is distinguished from Monitoring Device, which senses and records physiologic data rather than evacuating substances from the body.
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.