0U790DZ
Dilation Uterus to No Qualifier with Intraluminal Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | 7 Dilation |
| Body Part | 9 Uterus |
| Approach | 0 Open |
| Device | D Intraluminal Device |
| Qualifier | Z No Qualifier |
Operation Definition
Expanding an orifice or the lumen of a tubular body part
Procedure Overview
Dilation procedures widen the cervix or another opening within the female reproductive tract to allow instruments to pass, fluid to drain, or the natural anatomy to function normally again. Cervical dilation is the most familiar example, performed to open the cervical canal before a dilation and curettage, before placement of an intrauterine device, or to relieve cervical stenosis that is causing painful or obstructed menstrual flow.
The procedure can be done mechanically, using graduated dilator rods of increasing size, or with medication such as misoprostol or a laminaria stick that gradually softens and opens the cervix over several hours. Dilation is often a preparatory step that enables a subsequent procedure rather than a treatment on its own, though in cases of cervical stenosis or scarring it can directly relieve a patient's symptoms by restoring normal passage.
Anatomy & Axis Detail
Uterus
The uterus is the muscular organ that houses a pregnancy, and dilation of the uterine body refers to widening its cavity or the internal os beyond simple cervical dilation, a maneuver used to facilitate access for intrauterine instrumentation or to relieve a contracted or stenotic cavity. This is distinct from cervical dilation, which targets the cervical canal itself, and is instead applied to the corpus when the procedure requires enlarging the endometrial cavity's effective space, such as before certain hysteroscopic interventions. Because the myometrium is thick and vascular, excessive force risks perforation, so graduated dilators or hysteroscopic distension media are used under controlled pressure. Coding at this body part is reserved for cases where the uterine corpus itself, rather than the cervix, is the structure being widened.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Device: Intraluminal Device
Intraluminal Device denotes a single device, such as a stent or occlusion device, positioned within the lumen of a tubular body part like a vessel, duct, or airway to maintain patency or occlude flow. It carries no drug coating or radioactivity, distinguishing it from the drug-eluting, radioactive, and bioactive intraluminal device values, and from Extraluminal Device, which sits outside rather than inside the lumen.
Coding & Documentation
The operative or procedure note should explicitly describe widening of the cervical canal or another tubular opening, typically stating the size or degree of dilation achieved and the method used. When dilation is performed solely to gain access for another procedure, such as curettage or hysteroscopy, coding guidelines generally consider it a component of that other procedure rather than a separately reportable code, and coders should check whether the two are bundled under the same operative episode. A frequent error is coding Dilation as a standalone procedure when it was clearly incidental to a more definitive intervention performed immediately afterward in the same session.