March 12, 2012 | | Comments 0
Print This Post
Email This Post

ICD-10-PCS root operations: Avoid confusion between excision and resection

The ICD-10-PCS defines root operations excision and resection in a very similar way.
Excision is cutting out or off, without replacement, a portion of a body part. Coders should report the qualifier Diagnostic to identify excision procedures that are biopsies. Physicians use sharp instrument such as scalpel, wire, scissors, bone saw, and electrocautery tip during excision procedures.

Resection is very similar, except it includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS. ICD-10-PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs and regions of the intestine.
Coders will report Resection of the specific body part whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.

For example, the physician performs a left upper lung lobectomy. Coders would report a Resection of upper lung lobe, left, rather than Excision of lung, left.

In some situations, the physician may not be sure whether an entire body part is removed. For example, the physician may set out to remove an entire chain of lymph nodes. Because so many nodes are part of the chain, the physician may not be sure whether all were removed and may document that in the record. The coder must determine whether to code a resection (all of the nodes removed) or excision (some of the nodes removed). In this case, because the physician intended to remove all of the lymph nodes, the coder would report a resection.

Entry Information

Filed Under: Coding

Tags:

Michelle A. Leppert About the Author: Michelle A. Leppert, CPC, is a senior managing editor for JustCoding.com. JustCoding provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.

In addition, she writes and edits the HCPro publication, Briefings on Coding Compliance Strategies. Email her at mleppert@hcpro.com.

RSSPost a Comment  |  Trackback URL

*