What are the differences between excision and resection?
The important distinction between excision and resection is if a portion or the entire body part is excised
The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically reported in the hospital inpatient setting. The medical and surgical procedure codes contain seven characters, with each character representing one particular aspect of the procedure. The third character defines the root operation, or the objective of the procedure.
ICD-10-PCS Root Operations
There are 31 root operations in the medical and surgical section, which are arranged in groups with similar attributes (see the table “Medical and Surgical Section Root Operations” on page 59 for an alphabetical listing of all 31 root operations in the medical and surgical section).
The 31 root operations are arranged into the following groupings:
• Root operations that take out some/all of a body part
• Root operations that take out solids/fluids/gasses from a body part
• Root operations involving cutting or separation only
• Root operations that put in/put back or move some/all of a body part
• Root operations that alter the diameter/route of a tubular body part
• Root operations that always involve a device
• Root operations involving examination only
• Root operations that include other repairs
• Root operations that include other objectives
Root Operations that Take Out Some or All of a Body Part
The first grouping includes the following root operations:
Excision—Root Operation B
Excision is used when a sharp instrument is used to cut out or off a portion of a body part without replacement. All root operations employing cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to:
• Bone saw
• Electrocautery tip
The qualifier “diagnostic” is available to identify excision procedures that are biopsies.
Examples of excision are partial nephrectomy, liver biopsy, breast lumpectomy, excision of cyst, sigmoid polypectomy, or excision of melanoma.
Bone marrow and endometrial biopsies are not coded to excision. Instead they are coded to the root operation extraction, with the qualifier diagnostic used to identify the biopsy.
If a diagnostic excision (biopsy) is followed by a therapeutic excision at the same procedure site or resection of the body part during the same operative episode, only the therapeutic excision or resection is coded (e.g., for a breast biopsy followed by partial mastectomy at the same procedure site, only the partial mastectomy procedure is coded).
Resection—Root Operation T
Resection is similar to excision except it involves cutting out or off, without replacement, all of a body part. Resection includes all of a body part or any subdivision of a body part having its own body part value in ICD-10-PCS, while excision includes only a portion of a body part.
Examples of resection are total nephrectomy, total lobectomy of lung, total mastectomy, resection cecum, prostatectomy, or cholecystectomy.
Resection of a specific anatomical subdivision body part is coded whenever possible, rather than excision of the less specific body part (e.g., right upper lung lobectomy is coded to resection of upper lung lobe, right, and not to excision of lung, right).
The important distinction between excision and resection is if a portion or the entire body part is excised. A body part in ICD-10-PCS is not always an entire organ with some body part values being a subdivision of a particular organ. However, the body part value may be an entire organ, such as the organs of the gallbladder, prostate, or appendix.
When a procedure is performed on the body part, it is necessary to know if the entire body part was excised. For e.g.: A prostatectomy is the removal of the prostate, while a transurethral resection of the prostate removes the section of the prostate causing symptoms.
When an entire lymph node chain is cut out, the appropriate root operation is resection. When a lymph node(s) is cut out, the root operation is excision.
Some organs such as the liver, stomach, and lung have subdivisions of body parts.
• The liver contains right lobe and left lobe, the stomach includes the pylorus as a specific body part, and the lung has multiple body parts such as right and left upper lobe, right middle lobe, and right and left lower lobe.
• Therefore if the entire right middle lobe of the lung was removed, resection would be assigned rather than excision, because this is a complete body part per ICD-10-PCS.