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Resection Breast, Bilateral to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | T Resection |
| Body Part | V Breast, Bilateral |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection procedures on the skin and breast involve cutting out an entire body part rather than a sample or lesion. In this family, that most often means a mastectomy for breast cancer, or occasionally full-thickness removal of skin over a defined region, such as the entire nipple-areolar complex. The defining feature is completeness: the surgeon takes the whole named structure, not a margin around a mass.
These operations are done when disease, most commonly malignancy, has progressed to the point where partial removal would leave unacceptable risk of recurrence, or when the anatomy itself is being eliminated for prevention, such as a prophylactic mastectomy in a patient with a strong genetic predisposition. Reconstruction, if performed, is coded separately as its own procedure.
Recovery and follow-up depend heavily on what was resected and why, but the shared thread is that the tissue removed does not grow back and no portion of the original structure remains in that location.
Anatomy & Axis Detail
Breast, Bilateral
Bilateral breast resection describes complete removal of both breast glands in a single operative episode, most often performed prophylactically in patients with strong hereditary cancer risk such as BRCA mutations, or therapeutically when cancer or extensive disease affects both breasts simultaneously. Performing the procedure bilaterally allows for symmetric reconstruction planning when reconstruction is pursued, and surgeons often use matching techniques (skin-sparing, nipple-sparing, or simple mastectomy) on both sides to support that goal. Each breast is anatomically independent with its own vascular and lymphatic supply, so operative time and complexity roughly double compared to a unilateral procedure, though the bilateral nature is captured with this single combined code. Any associated axillary node procedures are documented separately from the breast resection itself.
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.
Coding & Documentation
The operative note must state that the entirety of the body part, such as the whole breast, was removed, not just a nodule or wedge. Pathology confirming a full specimen and the surgeon's language describing complete removal are what supports Resection over Excision.
The most common assignment error is choosing Resection when the documentation actually describes a partial procedure, such as a lumpectomy or partial mastectomy, which is coded to Excision instead. Coders also sometimes miss that skin resections are distinct from breast resections at the body part level, even though both fall under the same root operation, so the correct body part character still has to reflect exactly which structure, left or right breast, or a specific skin region, was taken.