0VP487Z
Removal Prostate and Seminal Vesicles to No Qualifier with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | V Male Reproductive System |
| Operation | P Removal |
| Body Part | 4 Prostate and Seminal Vesicles |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | 7 Autologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
Removal procedures in this family involve taking out a device that was previously placed in a structure of the male reproductive system, such as a penile prosthesis, testicular prosthesis, or a drain, rather than treating native tissue. These are performed when a device has served its purpose, malfunctioned, become infected, or needs to be exchanged for a different device.
Patients encounter these procedures most often after a prior implant surgery, such as removal of a penile implant due to mechanical failure, erosion, or infection, or removal of a testicular prosthesis that was placed after orchiectomy. Depending on the reason for removal, a new device may or may not be placed during the same operative session, which affects how the encounter is coded overall.
Anatomy & Axis Detail
Prostate and Seminal Vesicles
The prostate and seminal vesicles are grouped as a single body part because they are anatomically adjacent and commonly removed together, most often for localized or locally advanced prostate cancer, where the seminal vesicles are frequent sites of early extraprostatic tumor spread and their removal alongside the prostate improves the chance of a complete cancer resection. This combined removal, typically performed as a radical prostatectomy, requires careful dissection near the neurovascular bundles responsible for erectile function and the bladder neck, and the seminal vesicles' proximity to the vas deferens ampullae and rectum makes their inclusion technically significant for surgical planning. Documentation should confirm both structures were taken out together, since removal of the prostate alone or the seminal vesicles alone without the paired structure would be coded using a different, single-structure body part value.
Approach: Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening Endoscopic describes instrumentation introduced through a natural orifice or a surgically created opening while using an endoscope for visualization, as in a routine colonoscopy performed through the anus. It differs from the plain Via Natural or Artificial Opening value by the added scope, and from Percutaneous Endoscopic by using an existing passage rather than a new skin puncture.
Device: Autologous Tissue Substitute
Autologous Tissue Substitute identifies a device value where material harvested from the patient's own body, such as an autograft, is used to replace or reconstruct a body part. Its defining feature is tissue origin from the patient, setting it apart from Nonautologous Tissue Substitute, sourced from a donor or animal, and Synthetic Substitute, made of manufactured material.
Coding & Documentation
A Removal code is assigned only when a device is being taken out and documentation confirms no new device is being put in through the same procedure; if a device is removed and immediately replaced, coders instead consider whether Revision or a Removal-plus-Insertion combination better reflects what was documented. The operative note should name the specific device removed, such as inflatable penile prosthesis components or a testicular implant, and confirm complete extraction.
A common mistake is coding Removal when the physician actually performed a Revision, which corrects or adjusts a malfunctioning device without full removal and replacement, or when a device is removed and a new one is placed in the same operative episode, which requires reporting both Removal and Insertion rather than Removal alone. Coders should also verify the body part reflects where the device was located rather than the device type itself.