05DC3ZZ
Extraction Basilic Vein, Left to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 5 Upper Veins |
| Operation | D Extraction |
| Body Part | C Basilic Vein, Left |
| Approach | 3 Percutaneous |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Pulling or stripping out or off all or a portion of a body part by the use of force
Procedure Overview
Extraction procedures pull or strip a portion or the entirety of an upper vein out of the body using physical force, most commonly performed as vein stripping for veins affected by chronic disease or as removal of an indwelling line-associated vein segment. Unlike a clean surgical cut, this technique threads an instrument along the length of the vein and draws it out through one or two small incisions, which is why it is described using force rather than sharp dissection.
This approach is generally reserved for superficial upper extremity veins that have become diseased, scarred, or are being removed to harvest the vessel for use elsewhere, such as when a segment of arm vein is taken for use as a vascular graft. The vein is not replaced after extraction; it is simply removed from its original location.
Anatomy & Axis Detail
Basilic Vein, Left
The left basilic vein courses along the medial aspect of the forearm and upper arm and is commonly used for vascular access, including basilic vein transposition fistulas for dialysis, which predisposes it to retained catheter fragments or wall-adherent thrombotic material. Extraction here means surgically removing that embedded matter from the vessel rather than aspirating free clot, often through a limited incision given the vein's superficial location. Surgeons account for any prior access surgery on this vein, since scarring from previous fistula creation or catheter placement can make dissection more involved than in a virgin vessel. Because the basilic vein is a preferred site for future dialysis access, documenting the left-sided procedure precisely helps preserve accurate vascular access history for subsequent planning.
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
The operative note should use language consistent with pulling, stripping, or avulsing the vein rather than cutting it free, since that distinguishes extraction from excision at the root operation level. Coders should confirm whether the extracted vein was used as graft material for another procedure performed in the same operative session, which would require an additional code for the harvesting purpose as well as the destination procedure.
A frequent error is coding routine vein harvesting for coronary or peripheral bypass grafting under the wrong body system, since the vein being harvested is coded to its own body part in the venous system even though it will be used elsewhere. Coders also sometimes default to extraction for any vein removal regardless of technique, when the physician's documentation actually describes sharp excision.