0CTR0ZZ
Resection Epiglottis to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | C Mouth and Throat |
| Operation | T Resection |
| Body Part | R Epiglottis |
| 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
This family covers the complete surgical removal of a mouth or throat structure, performed without replacing it with any substitute material. Tonsillectomy, adenoidectomy, total glossectomy for tongue cancer, and total laryngectomy are the best-known examples, though resection also applies to complete removal of smaller structures such as the uvula or the epiglottis when the entire structure is taken. The defining feature is that the whole body part, not just a piece of it, is removed.
These procedures are most often performed to treat cancer, to relieve chronic infection or obstruction as with recurrent tonsillitis or sleep apnea, or to address a severely diseased structure that cannot be salvaged. Because losing an entire structure such as the tongue or larynx has major consequences for eating, breathing, and speaking, resection is frequently followed by reconstructive procedures performed either in the same operative session or as a staged second surgery.
Anatomy & Axis Detail
Epiglottis
The epiglottis is the leaf-shaped cartilaginous flap at the base of the tongue that folds over the laryngeal inlet during swallowing to prevent aspiration. Resection of the epiglottis entails its complete surgical removal, a step sometimes taken during treatment of supraglottic laryngeal cancer or severe epiglottic pathology when the structure cannot be preserved. Because the epiglottis plays a central protective role in airway safety, its total removal carries significant implications for postoperative swallowing function and often necessitates additional reconstructive or compensatory measures to reduce aspiration risk. Surgeons typically access the epiglottis through the oral cavity or via a laryngeal approach, and documentation should clearly distinguish complete resection from partial excision or debulking procedures that leave a remnant of the cartilage in place.
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
Coders need documentation confirming that an entire named body part was removed, not merely a lesion, margin, or portion of it; operative notes should describe complete excision of the structure by name, such as "total glossectomy" or "complete tonsillectomy." The most common error is applying resection when only a partial removal occurred, which should instead be coded as excision, or when the structure removed is better classified as an entire versus a specific defined body part in the ICD-10-PCS body part table. Coders should also verify whether reconstruction was performed in the same session, since that requires an additional replacement or supplement code alongside the resection.