0LTH0ZZ
Resection Perineum Tendon to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | L Tendons |
| Operation | T Resection |
| Body Part | H Perineum Tendon |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection removes an entire tendon, or a clearly defined tendon body part, without putting in any replacement material. This is a less common tendon procedure than repair or reposition, and it is typically performed when a tendon is so severely diseased, degenerated, or tumor-involved that removing it entirely is the safest or most effective option, rather than attempting to preserve and repair it.
Examples include excising a tendon segment infiltrated by a soft tissue tumor, removing a chronically diseased tendon that is causing ongoing pain and dysfunction with no reasonable prospect of repair, or excising an entire tendon as part of managing a severe infection that has destroyed the tissue. Because tendons connect muscle to bone, complete resection without any subsequent reconstruction can leave a functional deficit, so it is often paired with a separate reconstructive procedure, sometimes performed later, to restore movement.
Anatomy & Axis Detail
Perineum Tendon
The perineum's tendinous structures, most notably the central tendon of the perineum where multiple pelvic floor muscles converge, form a critical anchor point supporting the pelvic organs and maintaining continence, and this single body part value covers tendons in that region without laterality. Resection here is uncommon and typically reserved for cases involving tumor, severe obstetric injury with nonviable tissue, or chronic fistulizing disease that has destroyed the tendon's integrity. Because the central tendon serves as a convergence point for the bulbospongiosus, external anal sphincter, and levator ani attachments, its complete removal carries functional consequences for pelvic floor support and often necessitates reconstructive repair in the same setting. The confined, structure-dense perineal space also raises the risk of injury to the anal sphincter or urogenital structures during dissection, so operative documentation should clearly delineate the tendon excised from the surrounding muscle and connective tissue.
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
This root operation applies only when an entire named tendon body part, not merely a segment or the whole tendon down to its full anatomic extent, is being cut out and nothing biological or synthetic is placed to take its structural role. Coders should confirm the operative note describes complete excision of the tendon at that body part value, and check whether any reconstructive graft was placed at the same time, since combined excision and grafting is coded as Replacement instead.
A common assignment mistake is applying Resection when only part of a tendon was removed and the remaining tendon was repaired or trimmed, which should instead be coded as Excision or Repair depending on the amount and intent of tissue removed. Coders should also watch for tumor cases where a wider excision spans tendon and adjacent soft tissue, which may require coding to more than one body system.