0TB78ZX
Excision Ureter, Left to Diagnostic with No Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | T Urinary System |
| Operation | B Excision |
| Body Part | 7 Ureter, Left |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | Z No Device |
| Qualifier | X Diagnostic |
Operation Definition
Cutting out or off, without replacement, a portion of a body part
Procedure Overview
Excision in the urinary system involves cutting out a piece of an organ, such as a wedge of kidney tissue for biopsy, a section of bladder wall containing a suspicious lesion, or part of a ureter, while leaving the rest of the structure intact. It is performed to diagnose disease by examining tissue under a microscope, or to remove a localized abnormal area without sacrificing the whole organ.
Anatomy & Axis Detail
Ureter, Left
The left ureter carries urine from the left renal pelvis to the bladder along a retroperitoneal course that crosses the iliac vessels and runs medial to the gonadal vessels. Excision here removes a portion of this muscular tube, typically for a segment involved by a stricture-associated tumor, a fibrotic or ischemic segment, or a localized malignancy such as urothelial carcinoma confined to one length of duct. Because the ureter is a conduit rather than a reservoir, removing a segment usually requires reconstruction, such as ureteroureterostomy or reimplantation, performed as a separate procedure from the excision itself. Coders should confirm from the operative note whether the resected tissue represents a discrete segment (Excision) versus the entire ureter (Resection), and note laterality explicitly since right and left ureters are captured under separate values.
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.
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
Assignment depends on identifying the exact body part biopsied or partially removed and the surgical approach (open, percutaneous, or via endoscope). Operative and pathology notes together confirm that only a portion of the structure was taken, since removal of an entire organ is coded as Resection instead. A frequent mistake is defaulting to Excision for any biopsy language without checking whether the documentation actually describes complete organ removal, or failing to code a closed (percutaneous needle) biopsy separately from an open surgical biopsy performed during the same encounter.