Coding Tip: Root Operation Selection Excision vs. Resection
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
Selecting the Appropriate Root Operation – Excision vs. Resection
ICD-10 has now been into play going on four years as October approaches, but we still see coders struggling with reporting of the root operations excision vs. resection. Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
Root Operation “Excision”
This root operation would be selected with the physician takes out some or all of a body part without replacement. If only a portion of the body part is removed then this is coded as an excision. Sometimes the surgeon may document “partial resection” and the coder can correlate this to the root operation of “excision” as long as the detail of the operation also supports that this was the procedure that was accomplished.
The most common errors HIA reviewers see are in the intestines, but it can be in other places of the body as well. When coding some of the intestinal procedures, if the physician uses the terminology of “resection of sigmoid” but in the same note goes on to document that the sigmoid colon was then anastomosed to another site (possibly the transverse) then it is would not be coded as resection. If it were a resection, there would be no remaining sigmoid to use for the anastomosis.
- Excision/removal of inner outer quadrant of the breast. Even if the surgeon documented that he “resected” the inner outer quadrant of the breast, it is still coded to the root operation “excision.”
- Excision of upper pole of right kidney. The upper pole is only a portion of the body part kidney so it is coded as excision even when the surgeon may describe this as a resection.
- Excision/removal of portion of the sigmoid colon (example is in the above paragraph)
- Excision of lesion of the left lobe of the liver. This is stating that only an excision of the lesion was done and if that is supported by the details of the procedure, then it is coded as excision even when the surgeon may document the term “resection of lesion of the left lobe of the liver.” Unless the details of the surgery support that the entire left lobe of the liver was removed this is coded to the root operation “excision.”
Root Operation “Resection”
This root operation would be selected when the physician removes all of a body part without replacement. When resection of an organ is completed, no portion of that specific organ is left behind. The body part key will be necessary on some of these to determine if certain lobes are considered a body part (such as lung or liver). If ICD-10-PCS contains a specific body part for anatomical subdivision of a body part, the root operation “resection” would be used when all of that specific lobe (anatomical subdivision) is removed.
- Cholecystectomy (removal of the entire gallbladder)
- Mastectomy of the left breast (the entire breast is removed and not just a quadrant or mass)
- Left upper lung lobectomy (removal of the entire left upper lobe of the lung) Even though the entire lung is not removed, since ICD-10-PCS contains a specific body part for anatomical subdivision of the lung, this is coded to the root operation “resection.”
- Sigmoidectomy (removal of the entire sigmoid colon). The operative note should not mention that the sigmoid was anastomosed as that would indicate an excision only was completed and a query may be needed to clarify, depending on the remainder of the record documentation and pathology report findings.
- Removal of entire left lobe of the liver. Even though the entire liver is not removed, since ICD-10-PCS contains a specific body part for anatomical subdivision of the liver, this is coded to the root operation “resection.”
Remember to review the entire operative note when coding procedures and not just from the title of the procedure. The physicians are not required to use any specific terminology to report what they perform, only details of the surgery. It is the coder’s responsibility to be able to interpret the details of the surgery and select the correct root operation.
ICD-10-PCS Official Guidelines for Coding and Reporting 2019
ICD-10-PCS Reference Manual
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
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Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
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