0TB64ZZ
Excision Ureter, Right to No Qualifier with No Device, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | T Urinary System |
| Operation | B Excision |
| Body Part | 6 Ureter, Right |
| Approach | 4 Percutaneous Endoscopic |
| 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, Right
Excision of a portion of the right ureter removes a segment containing a stricture, a urothelial tumor, or scarred tissue from prior injury, without removing the ureter's entire length. Because the ureter is a narrow, thin-walled tube, even a limited excision typically requires reconstruction, such as ureteroureterostomy or reimplantation into the bladder, to restore urinary continuity, and that reconstructive step is documented separately from the excision itself. The right ureter's course near the appendix and cecum makes prior abdominal or pelvic surgery in that region a relevant consideration when a stricture or fibrotic segment is being excised, and operative notes should specify the segment's location and extent removed.
Approach: Percutaneous Endoscopic
Percutaneous Endoscopic combines a puncture through skin or mucous membrane with insertion of an endoscope to visualize the procedure internally, as in laparoscopic cholecystectomy. It is distinguished from plain Percutaneous by the presence of scope-guided visualization, and from Via Natural or Artificial Opening Endoscopic by its route being a new puncture rather than an existing orifice or stoma.
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.