0LTH4ZZ
Resection Perineum Tendon to No Qualifier with No Device, Percutaneous Endoscopic 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 | 4 Percutaneous Endoscopic |
| 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: 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.
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.