0UPD8HZ
Removal Uterus and Cervix to No Qualifier with Contraceptive Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | P Removal |
| Body Part | D Uterus and Cervix |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | H Contraceptive Device |
| 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 or on a female reproductive organ, rather than treating the organ or tissue itself. Common examples include removing an intrauterine device, a pessary used for prolapse support, a vaginal packing or drain, or a surgical mesh or sling material used in prior reconstructive surgery. The organ housing the device is not being treated for disease during this procedure; the focus is solely on extracting the implanted or inserted material.
Patients encounter this family of procedures for many reasons - an IUD reaching the end of its approved lifespan, a device causing discomfort or complications, or a temporary object like packing that was always meant to come out after a set period. Depending on the device and how it was originally placed, removal can be a simple office procedure or require a return trip to the operating room, particularly if the device has become embedded or scarred into surrounding tissue.
Anatomy & Axis Detail
Uterus and Cervix
The uterus and cervix are removed together when disease affects the corpus and the cervical canal cannot be left safely in place, or when the two are excised as a unit rather than separately coded. Indications include malignancy spanning both structures, extensive fibroid disease, or a total hysterectomy performed for benign conditions such as adenomyosis or refractory bleeding where the surgeon takes the cervix along with the body of the uterus. Because the cervix forms the boundary with the vagina, its removal requires securing the vaginal cuff, and nearby structures such as the ureters, bladder, and uterosacral ligaments are at risk during dissection. Coding this combined removal depends on documentation making clear that both the corpus and cervix were taken out, distinguishing it from a supracervical procedure that leaves the cervical stump behind, and from removal limited to the cervix alone.
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: Contraceptive Device
A contraceptive device is an implant placed to prevent pregnancy, such as an intrauterine device or a subdermal hormonal rod, and is coded to reflect the device left in place after the procedure. It is a distinct device category from other reproductive system implants and is not used interchangeably with diagnostic or therapeutic devices placed for other indications.
Coding & Documentation
This root operation is coded when a device is taken out and nothing is put in its place during that same encounter; documentation should identify the specific device removed and confirm no new device was inserted, since a simultaneous removal and replacement is captured differently. Coders need to verify the device type against the correct device value, distinguishing, for instance, an IUD from a pessary from mesh, as each has its own qualifying detail. A frequent error is coding Removal alone when a device is taken out and immediately replaced with a new one in the same session, which instead calls for a distinct combination of Removal and Insertion, or in some code sets a single replacement concept; another is overlooking Removal entirely when it happens incidentally during a different primary procedure, such as taking out an IUD before a hysteroscopy.