0LU207Z
Supplement Shoulder Tendon, Left 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 | U Supplement |
| Body Part | 2 Shoulder Tendon, Left |
| Approach | 0 Open |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part
Procedure Overview
Tendon supplement procedures reinforce or augment a weakened or torn tendon using a patch or graft rather than replacing the tendon outright. The added material, whether a strip of the patient's own tissue, tissue from a donor, or a synthetic mesh, is layered onto or into the existing tendon to restore its structural strength. Surgeons turn to this approach when a tendon is intact enough to preserve but too degenerated or thin to hold a repair on its own.
Common settings include rotator cuff surgery, where a graft is placed over a repaired cuff tendon to reduce re-tear risk, and reinforcement of the Achilles or patellar tendon after chronic tendinosis has thinned the tissue. The goal is to give the native tendon extra load-bearing capacity while it heals, rather than to substitute for missing tendon.
Recovery typically involves a period of immobilization followed by graduated physical therapy, since the reinforced tendon still needs to regain flexibility and strength over months.
Anatomy & Axis Detail
Shoulder Tendon, Left
The left shoulder's tendinous structures, principally the supraspinatus, infraspinatus, subscapularis, and long head of biceps, are subject to the same wear patterns as the contralateral side, often from repetitive overhead use or degenerative change. Supplement is used when a torn or attenuated tendon requires added structural support beyond primary suture repair, commonly through a bioinductive or dermal allograft patch placed over the repaired tendon edge. The confined subacromial space and the need to preserve the coracoacromial arch make graft placement technically demanding, and surgeons must balance reinforcement with maintaining joint mobility. Coders should note the laterality explicitly, as left and right shoulder tendon procedures are frequently performed in staged or bilateral cases and must not be conflated.
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
Assigning Supplement requires operative documentation stating that native tendon tissue remained in place and was reinforced with added material, not excised and replaced. The operative note should specify the material used (autograft, allograft, or synthetic) and its anatomical placement, since the seventh-character device value depends on this.
A frequent coding error is confusing Supplement with Repair when a surgeon simply oversews a small tear without adding graft material, or with Replacement when the graft entirely substitutes for a resected segment of tendon. Coders should also confirm the specific tendon involved, since the Tendons body system in ICD-10-PCS groups by region rather than by individual named tendon, and imprecise documentation can lead to selecting the wrong body part value.