0HBW3ZX
Excision Nipple, Right to Diagnostic with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | B Excision |
| Body Part | W Nipple, Right |
| Approach | 3 Percutaneous |
| Device | Z No Device |
| Qualifier | X Diagnostic |
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
Nipple, Right
The right nipple, including the nipple papilla and immediately adjacent areolar tissue, is excised for conditions such as Paget disease of the breast, chronic non-healing nipple lesions, symptomatic accessory tissue, or as part of gender-affirming or reconstructive procedures rather than for typical fibroadenoma or cyst removal, which involve deeper breast parenchyma instead. Because the nipple contains the terminal openings of the lactiferous ducts, excision here can affect future lactation and sensation, considerations that are usually discussed with the patient beforehand. The nipple-areolar complex has a rich sensory nerve supply, so even a limited excision can result in altered sensitivity. This body part is coded separately from breast tissue excision, so operative notes must be reviewed carefully to determine whether the nipple itself, rather than underlying glandular tissue, was the structure removed.
Approach: Percutaneous
Percutaneous describes entry by needle or instrument puncture through the skin or mucous membrane to reach the site of the procedure, without cutting the tissue open or using a visualizing scope. It differs from Open in that the site itself is never exposed, and from Percutaneous Endoscopic in that no endoscope is used to see internal structures. Common examples include needle biopsies and injections.
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
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.