0CTR4ZZ
Resection Epiglottis to No Qualifier with No Device, Percutaneous Endoscopic 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 | 4 Percutaneous Endoscopic |
| 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: Percutaneous Endoscopic
Percutaneous Endoscopic combines a puncture through skin or mucous membrane with insertion of an endoscope to visualize the procedure internally, as in laparoscopic cholecystectomy. It is distinguished from plain Percutaneous by the presence of scope-guided visualization, and from Via Natural or Artificial Opening Endoscopic by its route being a new puncture rather than an existing orifice or stoma.
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.