0FPB0KZ
Removal Hepatobiliary Duct to No Qualifier with Nonautologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | F Hepatobiliary System and Pancreas |
| Operation | P Removal |
| Body Part | B Hepatobiliary Duct |
| 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
Removal procedures take out a device that was previously placed in the liver, gallbladder, bile ducts, or pancreas, such as a biliary stent, drainage catheter, or T-tube, without replacing it with a new device or repairing the underlying tissue. These devices are typically placed to relieve obstruction, drain fluid, or support healing after another procedure, and removal occurs once they are no longer needed or need to be exchanged outside the same operative episode.
A clinician removes such a device when the underlying condition it was treating has resolved, when the device has become blocked or infected, or as a planned step some weeks after it was placed to allow a duct or surgical site to heal on its own. This is common after gallbladder or bile duct surgery, endoscopic stent placement for a stricture or stone, or drainage of a pancreatic pseudocyst.
The procedure is limited strictly to taking the device out; if a new device is placed at the same time, that placement is coded separately as its own procedure.
Anatomy & Axis Detail
Hepatobiliary Duct
This code covers removing a device from one of the ducts of the biliary tree outside the liver, most often a biliary stent or percutaneous transhepatic drainage catheter placed to relieve obstruction from a stricture, stone, or tumor. Because these ducts are narrow and prone to re-stenosis, stents are frequently exchanged or removed once the underlying obstruction has been treated or has resolved, and the retrieval is commonly performed endoscopically using a duodenoscope or through an existing percutaneous tract. The procedure requires care to avoid dislodging debris or causing duct injury during extraction, and documentation should specify which duct and which type of device was removed, since biliary stents vary considerably in design and in how they are grasped and withdrawn.
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
Coders assign this code when documentation clearly states a specific device, such as a stent, drain, or T-tube, was taken out of the hepatobiliary or pancreatic system, and no replacement device was left in its place during that encounter. The body part value should reflect where the device was situated, and the approach should match how it was extracted, such as endoscopically or percutaneously.
A frequent error is failing to code Removal separately when a device is taken out and a new one is placed in the same encounter, since ICD-10-PCS requires both the removal and the insertion of the replacement to be captured as distinct procedures rather than bundled into a single code. Another common mistake is confusing removal of a retained device with excision of diseased native tissue, which belongs to a different root operation entirely.
Commonly Confused With
Removal is often confused with Revision, which is used when a malfunctioning device is being corrected or adjusted in place rather than taken out entirely, and with Change, which applies only when a similar device is removed and replaced within the same operative episode without cutting or puncturing the skin or a mucous membrane. The distinction rests on whether the device leaves the body permanently, is exchanged through the original external opening, or is repaired without removal.