01B00ZX
Excision Cervical Plexus to Diagnostic with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 1 Peripheral Nervous System |
| Operation | B Excision |
| Body Part | 0 Cervical Plexus |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | X Diagnostic |
Operation Definition
Cutting out or off, without replacement, a portion of a body part
Procedure Overview
This family describes procedures that remove a portion of a peripheral nerve or its associated tissue, such as taking a small nerve biopsy to diagnose conditions like vasculitis or amyloidosis, or removing a segment of nerve that contains a benign tumor such as a schwannoma or neurofibroma. Unlike a full nerve resection performed to eliminate the nerve's function entirely, this operation takes out only part of the structure while leaving the rest intact.
Patients typically undergo this procedure either because a diagnosis cannot be made without direct tissue sampling, or because a growth on the nerve needs to be removed for symptom relief or to rule out malignancy. Recovery depends heavily on which nerve was involved and how large a segment was taken, since sensory or motor deficits can result even from a partial excision.
Anatomy & Axis Detail
Cervical Plexus
The cervical plexus is formed by the anterior rami of C1 through C4 beneath the sternocleidomastoid muscle, supplying sensation to the neck, shoulder, and scalp along with motor fibers to strap muscles and, via the phrenic contribution, indirect diaphragmatic input. Excision of a portion of this plexus is generally performed for a discrete neuroma, schwannoma, or other mass lesion identified within the lateral neck, and the surgeon must work carefully to spare adjacent branches supplying unaffected territory. Because the plexus sits near the internal jugular vein, carotid sheath, and accessory nerve, dissection requires meticulous attention to preserve these structures. Postoperative numbness over the anterior neck and ear is a recognized consequence of removing plexus tissue, and this should be anticipated in surgical planning and consent.
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.
Qualifier: Diagnostic
Applied chiefly to Excision, this qualifier marks that tissue was removed specifically for diagnostic purposes, i.e., a biopsy intended for pathologic evaluation rather than to treat disease. It distinguishes biopsy-type excisions from therapeutic excisions of the same body part, which are coded without this qualifier even though the physical technique may be identical.
Coding & Documentation
Coders assign this family when the operative report describes cutting out part of a nerve or a lesion attached to it, with no replacement material used. The pathology report and surgeon's description of margins help confirm that a distinct portion, rather than the entire nerve, was removed. A frequent assignment error is applying Excision when the whole nerve was actually transected and not reconnected, which is more accurately captured as Resection in body systems that support it, or confusing a diagnostic nerve biopsy (still Excision) with an incisional biopsy of an unrelated soft tissue mass nearby. Documentation should also clarify whether the nerve itself or a surrounding structure, like a neuroma confined to scar tissue, was the target.