0BT20ZZ
Resection Carina to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | B Respiratory System |
| Operation | T Resection |
| Body Part | 2 Carina |
| 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 describes the complete surgical removal of an entire respiratory structure without replacing it, and in this body system it most often refers to pneumonectomy, the removal of an entire lung, most commonly performed for lung cancer that cannot be controlled with a smaller resection. It also covers total removal of a lobe when the whole lobe is taken, though partial lobe removal is classified differently.
These are major operations reserved for situations where disease, most often malignancy but sometimes severe infection or destroyed lung tissue, involves an entire anatomically distinct structure, making anything less than complete removal insufficient. Patients undergoing these procedures typically face a lasting reduction in lung capacity, so candidacy is carefully weighed against overall lung function beforehand.
Anatomy & Axis Detail
Carina
The carina is the ridge of cartilage where the trachea divides into the right and left main bronchi, a site with minimal room for error given its proximity to the heart, great vessels, and both lungs' airflow. Resection of the carina is reserved for tumors, typically bronchogenic carcinoma, that invade this junction and cannot be managed by a lobar or single-bronchus procedure alone. Because removing the carina eliminates the natural branch point of the airway, the operation is inseparable from reconstruction: the surgeon must fashion a new anastomosis joining the trachea to one or both main bronchi, often with a sleeve resection of adjacent bronchus. Documentation should reflect that this is a complex thoracic procedure carrying significant risk of anastomotic leak or stenosis, distinguishing it from simpler bronchial excisions.
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 report must clearly state that an entire named anatomical unit, a whole lung, a whole lobe, or the whole trachea, was removed, since ICD-10-PCS Resection requires completeness of that structure. A frequent coding error is applying Resection to a lobectomy when only part of a lobe was actually removed, or applying it to a wedge resection of lung tissue, both of which should be coded as Excision because they remove only a portion of the body part.