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Tenotomy, commonly known as tendon release, is a surgical procedure aimed at alleviating pain and restoring function in the elbow to shoulder region by addressing issues related to tendon inflammation or other disorders. This procedure is particularly relevant for conditions such as golfer's elbow (medial epicondylitis) and tennis elbow (lateral epicondylitis), which are characterized by pain and dysfunction due to tendon irritation or damage. During the tenotomy, a surgical incision is made over the elbow or upper arm to access the affected tendon. The surgeon carefully identifies the tendon and assesses the extent of any damage present. The procedure involves making a horizontal incision near the tendon’s attachment to the bone, followed by a longitudinal split of the tendon to facilitate the removal of any scar tissue that may be contributing to the patient's symptoms. In some cases, the loose end of the tendon may be sutured to adjacent fascial tissue to promote healing and restore function. After the tendon has been treated, the overlying soft tissues and skin are meticulously closed in layers to ensure proper healing. A splint is then applied to maintain the arm in the correct position during the recovery phase. It is important to note that this CPT® code is reported separately for each tendon that undergoes tenotomy, reflecting the individualized nature of the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
Tenotomy is indicated for various conditions affecting the tendons in the elbow to shoulder region. The following are explicitly provided indications for performing this procedure:
The tenotomy procedure involves several critical steps to ensure effective treatment of the affected tendon. The following procedural steps are outlined:
Post-procedure care following a tenotomy is essential for ensuring proper recovery and minimizing complications. Patients are typically advised to keep the arm immobilized in a splint for a specified period to allow the tendon to heal adequately. Pain management strategies may be implemented, including prescribed medications to alleviate discomfort. Physical therapy may be recommended after an initial healing period to restore strength and flexibility to the affected area. Patients should be monitored for any signs of infection or complications, and follow-up appointments are crucial to assess the healing process and adjust rehabilitation protocols as necessary. Adhering to post-procedure instructions is vital for achieving the best possible outcomes following a tenotomy.
| Short Descr | TNOT OPN ELBW TO SHO EA TDN | Medium Descr | TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON | Long Descr | Tenotomy, open, elbow to shoulder, each tendon | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 2 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2023-01-01 | Note | Short description changed. |
| Pre-1990 | Added | Code added. |
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