0TC60ZZ
Extirpation Ureter, Right 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 | C Extirpation |
| Body Part | 6 Ureter, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Taking or cutting out solid matter from a body part
Procedure Overview
Extirpation covers procedures that physically remove solid material from inside a urinary structure without cutting out any of the structure itself. Classic examples include removing a kidney or bladder stone through an open or endoscopic approach, clearing a blood clot obstructing the bladder, or taking out debris that has collected in a ureter. The material removed is abnormal - it does not belong there - and the underlying organ stays intact once it is gone.
Anatomy & Axis Detail
Ureter, Right
The right ureter transports urine from the right renal pelvis to the bladder, running a long retroperitoneal course that crosses the iliac vessels before entering the pelvis. Extirpation from this structure involves physically removing solid material lodged within its lumen, most commonly an obstructing ureteral calculus, blood clot, or sloughed tissue fragment causing colic or hydronephrosis, typically addressed through ureteroscopy with basket or forceps extraction, sometimes combined with lithotripsy to fragment larger stones first. This differs from excision, which removes ureteral tissue itself rather than an intraluminal obstruction. Because ureteral stones can lodge at characteristic narrow points, such as the ureteropelvic junction, where the vessel crosses the iliac vessels, or the ureterovesical junction, the specific location influences technique but not the coded body part value, which remains the ureter as a whole.
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
The coder needs documentation confirming that the object removed was solid matter foreign to normal anatomy, such as a calculus, clot, or necrotic material, and that no tissue resection occurred alongside it. The specific site and approach (percutaneous, transurethral, open) determine the code. A common assignment error is coding stone removal as Fragmentation when the stone was broken up and then extracted as pieces - if fragments are actually retrieved and removed, Extirpation may apply to the retrieval step in addition to Fragmentation for the breaking-up step, and coders sometimes capture only one of the two.