0HPU0KZ
Removal Breast, Left to No Qualifier with Nonautologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | P Removal |
| Body Part | U Breast, Left |
| Approach | 0 Open |
| Device | K Nonautologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
This family covers taking out a device that was previously placed in the skin or breast, without putting in a replacement. Common examples include removing a tissue expander after breast reconstruction is complete, taking out a wound vacuum-assisted closure device, removing a subcutaneous port or pump, or extracting sutures, staples, or drains that were left in place from an earlier procedure.
Removal is performed once the device has served its purpose, whether that means a temporary expander has stretched the skin enough for a permanent implant, an infection has resolved and hardware is no longer needed, or a wound has healed to the point that ongoing negative pressure therapy is unnecessary. In some cases the device is removed because it is malfunctioning, causing pain, or has become infected and must come out before treatment can continue.
The procedure itself can be as simple as an office visit to withdraw a drain, or it can require a return trip to the operating room to surgically extract a deeply seated expander or reservoir.
Anatomy & Axis Detail
Breast, Left
In the left breast, Removal captures extraction of a device such as an implant, tissue expander, surgical drain, or localization marker rather than excision of breast parenchyma. Implant or expander removal may follow capsular contracture, device rupture, infection, or a staged reconstructive plan transitioning from expander to permanent implant, and the fibrous capsule surrounding the device often requires careful dissection during extraction. Drains placed after left-sided mastectomy, lumpectomy, or reconstructive procedures are removed once drainage criteria are met. Clear laterality documentation matters here because the left breast's device history, such as expander fill volume or implant type, frequently differs from the right and directly determines correct code selection.
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.
Device: Nonautologous Tissue Substitute
Nonautologous Tissue Substitute refers to biologic material sourced from a donor or another species, such as an allograft or xenograft, used to replace a body part. It differs from Autologous Tissue Substitute by tissue origin outside the patient's own body, and from Synthetic Substitute by being biologic rather than manufactured material.
Coding & Documentation
Coding depends on clear documentation of what specific device was removed and where it was located, since skin and breast each have distinct body part values and a nonspecific note such as 'device removed' is not enough to assign a precise code. The operative report should confirm no new device was placed at the same encounter; if one was, the encounter belongs under Replacement instead.
A common mistake is coding Removal when the physician actually exchanged one device for another in the same session, which should be captured as Replacement rather than a standalone removal. Coders also sometimes overlook that removing sutures or superficial dressings that are not classified as procedural devices should not be coded at all, since ICD-10-PCS only captures removal of devices meeting the system's device definition. Confirming whether the device removal was performed via open incision or percutaneously is also essential for the approach character.