0TB70ZZ
Excision Ureter, Left to No Qualifier with No Device, Open 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 | 0 Open |
| 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 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: 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.
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.