0MBK3ZX
Excision Perineum Bursa and Ligament to Diagnostic with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | M Bursae and Ligaments |
| Operation | B Excision |
| Body Part | K Perineum Bursa and Ligament |
| 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 cut out a portion of a bursa or ligament without replacing it, leaving the remainder of the structure in place. This is done to remove diseased, damaged, or chronically inflamed tissue, such as a thickened bursa that has not responded to drainage or rest, or a partially torn ligament that needs debridement of frayed edges before repair.
A bursectomy, in which part of an inflamed bursa is removed, is a typical example, as is trimming away degenerated portions of a ligament during reconstructive surgery. Because only a portion of the structure is taken, the ligament or bursa continues to exist and function afterward, distinguishing this from a resection that removes the entire body part.
Excision is often performed as a standalone treatment for chronic bursitis or degenerative ligament disease, or as a preparatory step before repair or reconstruction.
Anatomy & Axis Detail
Perineum Bursa and Ligament
The perineum's bursae and ligaments include the connective tissue supporting the pelvic floor and perineal body, along with any bursal sacs that can form from chronic pressure or friction in this region, such as from prolonged sitting or obstetric trauma. Excision is generally performed to remove scarred or symptomatic ligamentous tissue following childbirth injury, to address a painful ischial bursa, or to resect tissue involved in a perineal mass. Because the perineum is anatomically compact and adjacent to reproductive, urinary, and rectal structures, precise documentation of the ligamentous or bursal origin of the excised tissue is essential to avoid confusion with excisions of the nearby genitourinary or gastrointestinal organs.
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
Coders should confirm the note describes cutting out and removing a specific portion of tissue that is sent to pathology or discarded, as opposed to simply releasing or draining the structure. If the entire bursa or ligament is removed, the correct root operation is Resection rather than Excision, so the extent of removal documented by the surgeon is critical.
A frequent error is coding debridement performed as part of a repair as a separate Excision when it was an integral, inherent part of the definitive procedure and should not be coded separately. Biopsies of ligament or bursa tissue also fall under Excision and require attention to the diagnostic qualifier.