For the past few weeks we have worked on root operations that take out some or all of a body part. We are going to continue our discussion, focusing on excision and resection procedures.
Coding problems for this week:
- Laparoscopic excision of right ovarian cyst followed by a total oophorectomy.
- Right breast lumpectomy followed by total mastectomy, open approach.
- 0UB04ZX; 0UT04ZZ
- 0HBT0ZX; 0HBT0ZX
Problem #1, Laparoscopic excision of right ovarian cyst, diagnostic.
To Locate: PCS Index > Excision > Ovary > Right > 0UB0 > Locate table 0UB and go across the row to finish building the code:
Excision of right ovary, percutaneous endoscopic approach
Problem #1, Part 2 cont’d, Right Oophorectomy
To Locate: PCS Index > Resection > Ovary > Right > 0UT0 > locate 0UT and go across the row to finish building the code:
Resection of right ovary, percutaneous endoscopic approach
Definition, Excision vs. Resection: Excision is defined as cutting out or off, without replacement, a portion of a body part, whereas Resection is defined as cutting out or off, without replacement, all of a body part
- The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.
- New Guidelines, B3.4a, B3.4b
- GL B3.4a, Biopsy Procedure: Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. For example, lymph node sampling, partial nephrectomy, liver biopsy by excision of tissue….
- GLB3.4b, Biopsy followed by more definitive procedure: If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, BOTH the biopsy AND the more definitive treatment are coded. For example, a biopsy of the breast followed by a partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded.
- Approach: Entry by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure. A puncture is made in the abdomen followed by insertion of the scope. This is considered a laparoscopy.
Problem #2, Right breast lumpectomy followed by total mastectomy.
To Locate: PCS Index > Lumpectomy > see Excision > Breast > Right > 0HBT > locate table 0HB and go across the row to finish building the code:
Excision of right breast, open approach, diagnostic
Problem #2, Part 2 cont’d, Mastectomy
To Locate: PCS Index > Mastectomy > see Resection, Skin and Breast > Breast > Right > 0HTT0ZZ> Even though the Index gives you the code, you should still refer to table 0HT and go across the row to verify that the code is correct:
Resection of right breast, open approach
NOTE: An ‘excision’ is coded when only a part of the organ is removed and there is a portion left behind.