Breakdown (mechanical) of muscle and tendon graft, subs

This code signifies a mechanical failure of a previously implanted muscle or tendon graft. This breakdown can involve issues such as rupture, displacement, or loosening of the graft itself, rather than an infection or inflammatory response. It indicates a structural compromise of the graft material.

Use this code when a patient presents for follow-up care or treatment related to a mechanical complication of a muscle or tendon graft that occurred after the initial healing phase. This applies to situations where the graft has failed due to non-biological reasons, such as a tear or detachment, and the patient is returning for assessment or intervention.

• Ensure documentation clearly specifies a mechanical breakdown, not an infection or rejection.
• Verify that this is a subsequent encounter for the complication, not the initial treatment of the graft.
• Always code with an external cause code (e.g., W00-Y38) if the mechanical breakdown was due to an external event.