0HDV0ZZ
Extraction Breast, Bilateral to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | D Extraction |
| Body Part | V Breast, Bilateral |
| Approach | 0 Open |
| 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 in this family involve pulling or stripping tissue from the skin or breast by mechanical force rather than cutting it free. The most familiar example is avulsion of a toenail or fingernail, where the nail plate is gripped and pulled from its bed to treat an ingrown nail, a chronic fungal infection, or trauma. Less commonly, the same approach is used to strip a foreign object or an adherent dressing material embedded in skin or breast tissue when it can be removed by force alone.
The procedure is chosen over excision because no cutting instrument separates the tissue - the material is simply extracted intact. It is often done under local anesthesia in an office or minor procedure setting, though more extensive avulsions may require sedation.
Patients undergo extraction to relieve pain, resolve infection, or remove a structure that is no longer functional, such as a permanently damaged nail.
Anatomy & Axis Detail
Breast, Bilateral
When Extraction is performed on both breasts, the coder is documenting a single procedure applied bilaterally rather than two separate lateral codes, which requires the physician's note to explicitly describe simultaneous, comparable removal of matter from each side. Clinically this might occur when necrotic tissue, debris, or loosened material must be cleared from both breasts during the same operative session, such as bilateral management of infection or trauma affecting symmetric anatomy. Because the bilateral body part value exists specifically to avoid coding the same encounter twice, it should only be used when the extraction technique and extent are genuinely mirrored on each side; asymmetric findings or differing methods on the right versus left would instead be captured with the individual laterality codes for accuracy.
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
A coder assigns a code from this family when the operative note explicitly describes tissue or a structure being pulled or torn away by force, not incised. Documentation should state the method (avulsion, stripping) and identify the specific structure removed, such as nail versus adjacent skin. A common mistake is defaulting to Extraction whenever a nail procedure is mentioned, when the surgeon actually excised nail matrix tissue with an instrument, which belongs under Excision instead. Another frequent error is failing to distinguish partial from total nail avulsion, which affects the qualifier selected.