0HQV8ZZ
Repair Breast, Bilateral to No Qualifier with No Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | Q Repair |
| Body Part | V Breast, Bilateral |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Procedure Overview
Repair procedures in the skin and breast are used whenever tissue needs to be restored to its normal structure after an injury or defect, and no other more specific root operation better describes what was done. Typical examples include suturing a skin laceration, closing a surgical wound that reopened, or repairing a breast defect that doesn't require reconstruction with an implant or flap.
This category functions as a default option in ICD-10-PCS: it applies when the objective is simply to put anatomy back together using the body's own tissue, without removing, replacing, or transferring tissue from elsewhere. It is commonly performed after trauma, dehiscence of a prior incision, or as the closing step following removal of a skin lesion when the surgeon simply reapproximates the edges rather than using a graft or flap.
Because Repair is the root operation of last resort, it is used only when the procedure doesn't fit any of the more specific root operations, such as suturing skin edges together rather than transferring a flap of tissue or inserting a graft.
Anatomy & Axis Detail
Breast, Bilateral
Bilateral breast repair refers to procedures performed on both breasts during the same operative episode, typically for symmetric trauma, dehiscence following bilateral mastectomy or reduction surgery, or simultaneous wound complications affecting both sides. This single body part value is used specifically when the same root operation, Repair, is carried out on both breasts, avoiding the need to code each side separately. Documentation should confirm that both breasts underwent comparable restorative closure rather than one side receiving repair while the other underwent a different procedure such as Replacement, which would require separate coding. Because bilateral breast surgery is often planned as a matched procedure for cosmetic or reconstructive symmetry, operative notes typically describe the technique applied to each breast, even though the code itself captures the bilateral nature in a single 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.
Coding & Documentation
Coders should verify from the operative note that the closure was a straightforward reapproximation of tissue and not a more complex reconstruction, since Repair is only assigned when no other root operation applies. Documentation should specify the anatomic site closed and confirm that no graft, flap, or synthetic material was used, since those findings point elsewhere.
The most frequent error is defaulting to Repair too quickly, when the physician actually performed a procedure like a flap transfer that should be captured under Transfer, or a breast reconstruction using a graft that belongs under Replacement or Supplement. Another common mix-up is coding a routine surgical closure at the end of an unrelated procedure, such as the incision closure following an excision, which is not separately coded because it is an integral part of the primary operation rather than a distinct repair.