0UPH03Z
Removal Vagina and Cul-de-sac to No Qualifier with Infusion Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | P Removal |
| Body Part | H Vagina and Cul-de-sac |
| Approach | 0 Open |
| Device | 3 Infusion 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
Vagina and Cul-de-sac
The vagina and cul-de-sac are grouped together here because the peritoneal pouch behind the vagina, between it and the rectum, is often excised in continuity with vaginal tissue during radical surgery. This combined removal is typically performed for malignancy that has spread from the cervix, vagina, or adjacent pelvic organs into the posterior vaginal wall and the rectovaginal space, or for extensive endometriosis obliterating the cul-de-sac. Because the rectum, ureters, and bladder base lie close to this plane, dissection carries meaningful risk of injury to those structures, and surgeons often document the extent of resection in relation to them. Coders should confirm that documentation supports excision of both the vaginal tissue and the cul-de-sac itself, rather than a vaginal procedure alone, since the combined body part value applies only when both are taken out together.
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: Infusion Device
Infusion Device denotes a device left in place to deliver medication, fluids, or other substances into a body part over time, such as an intrathecal or epidural pump. It is distinct from devices that merely monitor or mechanically support tissue, since its function is ongoing pharmacologic or fluid delivery rather than structural replacement. Common placements include the spinal canal, peritoneal cavity, and vascular access sites.
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.