0HBV8ZZ
Excision Breast, Bilateral to No Qualifier with No Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | B Excision |
| Body Part | V Breast, Bilateral |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, a portion of a body part
Procedure Overview
Excision procedures remove a portion of skin or breast tissue without replacing it, and this family spans everything from a shave biopsy of a suspicious mole to a lumpectomy removing a breast tumor with a margin of surrounding tissue. The common thread is that a defined piece of tissue, not the entire organ or structure, is cut away and typically sent to a pathology lab for examination.
Patients most often encounter this family when a mole, cyst, or lump needs to be evaluated or treated, or when a breast biopsy is needed to characterize a finding seen on imaging. Because only part of the body part is taken, the surrounding skin or breast tissue remains intact, which distinguishes these procedures from more extensive surgery that removes an entire structure.
Anatomy & Axis Detail
Breast, Bilateral
Bilateral breast excision refers to a single procedure in which discrete portions of tissue are removed from both breasts during the same operative session, most commonly for symmetric conditions such as bilateral fibroadenomas, gynecomastia in male patients, or synchronous bilateral cancers detected on screening. Performing the excisions together allows for a single anesthetic exposure and coordinated symmetry planning, which is particularly relevant when cosmetic outcome matters, such as in reduction-type excisions performed for symptomatic macromastia. Because each breast may have a different underlying indication or pathology, the operative note should clearly describe the tissue removed from each side even though the coded body part combines them. Margin assessment and specimen orientation are still performed independently for each breast's excised tissue to allow separate pathological evaluation.
Approach: Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening Endoscopic describes instrumentation introduced through a natural orifice or a surgically created opening while using an endoscope for visualization, as in a routine colonoscopy performed through the anus. It differs from the plain Via Natural or Artificial Opening value by the added scope, and from Percutaneous Endoscopic by using an existing passage rather than a new skin puncture.
Coding & Documentation
Documentation should describe the amount of tissue removed, any margins taken, and whether the intent was diagnostic (an excisional biopsy) or therapeutic. Coders must pay close attention to whether the note describes removal of only part of the breast or skin versus the entire body part, since removing an entire breast is coded to Resection rather than Excision even though both involve cutting tissue away. A common mistake is coding a partial mastectomy or wide local excision as Resection out of habit, or conversely under-coding a case that actually removed the whole breast as Excision.