0VPD7YZ
Removal Testis to No Qualifier with Other Device, Via Natural or Artificial Opening Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | V Male Reproductive System |
| Operation | P Removal |
| Body Part | D Testis |
| Approach | 7 Via Natural or Artificial Opening |
| Device | Y Other Device |
| 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
Testis
Removal at the testis in ICD-10-PCS refers to taking out a device previously placed within the organ, most often a silicone or saline testicular prosthesis implanted after orchiectomy for cancer, trauma, or torsion, or occasionally a biopsy marker left in place. The testis itself is a paired, encapsulated gland suspended in the scrotum by the spermatic cord, and any prosthesis sits within the residual tunica vaginalis space rather than replacing functional tissue. Removal is coded when the implant is taken out without a new device being placed in the same operative episode, whether because of infection, malposition, capsular contracture, patient dissatisfaction with size or feel, or planned staged revision. Because the scrotal pouch is shallow and mobile, the surgeon typically approaches through the original scrotal incision, and documentation should clarify whether the device is removed outright or removed and immediately replaced, which would instead be coded as Removal followed by Insertion.
Approach: Via Natural or Artificial Opening
Via Natural or Artificial Opening means the instrument reaches the target site by passing through an existing body orifice, such as the mouth or urethra, or a surgically created opening like a stoma, without additional incision or scope guidance. It is distinguished from the Endoscopic variant by the absence of a visualizing scope, and from External by actually traversing into the body through that opening.
Device: Other Device
Other Device is a catchall value used when a device remains in place but does not fit any of the specifically defined categories, such as tissue substitutes, drainage tubes, radioactive elements, or monitoring sensors. It allows coding of implanted or inserted devices that fall outside those named classifications.
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.