0VBC3ZZ
Excision Testes, Bilateral to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | V Male Reproductive System |
| Operation | B Excision |
| Body Part | C Testes, Bilateral |
| Approach | 3 Percutaneous |
| 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 describes cutting away a portion of a male reproductive organ while leaving the rest of that structure in place. Typical examples include a testicular biopsy to evaluate a mass or infertility, partial removal of an epididymal cyst, trimming redundant foreskin tissue during a revision, or taking a wedge of prostate tissue for diagnostic purposes. The goal is either to obtain a tissue sample for diagnosis or to remove a localized area of diseased or abnormal tissue without sacrificing the whole organ.
These procedures are ordered when imaging or physical exam finds a suspicious lump, cyst, or lesion that needs pathological evaluation, or when a benign growth is causing discomfort and only the affected portion needs to come out. Because part of the organ remains functional afterward, excision is generally reserved for focal problems rather than diffuse disease affecting the whole structure.
Anatomy & Axis Detail
Testes, Bilateral
Bilateral testes together constitute the paired gonadal organs responsible for the body's endogenous androgen supply and sperm production, each encased in its own tunica albuginea within the scrotum. When a cutting procedure removing only a portion of tissue is performed on both glands during the same operative episode, rather than a single side, it is most often for synchronous biopsy of suspicious lesions found on bilateral ultrasound, staged management of bilateral microlithiasis-associated masses, or symmetric debridement following bilateral trauma or torsion. Because fertility and hormonal reserve depend on preserved parenchyma from either side, surgeons take particular care to limit tissue loss and reconstruct the tunica on each gland individually. Coding this bilateral value requires operative documentation confirming that both testes, not just one, underwent excision in the same encounter.
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.
Coding & Documentation
Documentation should clearly state that only a portion of the organ was removed, name the specific structure, and indicate whether the intent was diagnostic sampling or therapeutic removal of abnormal tissue. Coders often default to Excision out of habit when the note actually describes removal of an entire organ, such as a full orchiectomy, which is Resection rather than Excision. Biopsy language deserves particular attention: a needle or incisional biopsy of the testis or prostate is still Excision with the diagnostic qualifier applied, and coders should not assume biopsies are automatically a different root operation. Pathology reports can help confirm exactly which structure and how much tissue was taken.