0UPM07Z
Removal Vulva to No Qualifier with Autologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | P Removal |
| Body Part | M Vulva |
| Approach | 0 Open |
| 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 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
Vulva
The vulva comprises the external female genital structures, including the labia majora and minora, clitoral hood, and surrounding skin, and its removal is most often performed for vulvar carcinoma, extensive intraepithelial neoplasia, or severe chronic disease unresponsive to other treatment. Because the vulva is richly innervated and supplied by superficial lymphatics that drain toward the inguinal nodes, the extent of excision, whether partial, simple, or radical, has direct implications for wound healing, sexual function, and the need for accompanying lymph node dissection. Documentation should specify how much vulvar tissue was excised and whether the procedure was limited to skin and subcutaneous tissue or extended to deeper structures, since more extensive excisions may cross into a different root operation such as Resection or Excision depending on whether the entire body part or only a portion was taken.
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: 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
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.