08TC3ZZ
Resection Iris, Right to No Qualifier with No Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 8 Eye |
| Operation | T Resection |
| Body Part | C Iris, Right |
| Approach | 3 Percutaneous |
| 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 in the eye involve cutting out an entire body part without replacing it, most notably enucleation of the globe for conditions such as intraocular tumors, severe trauma, or a blind and painful eye, and evisceration or excision of other complete ocular structures like the lacrimal gland. These are definitive, irreversible procedures reserved for situations where a structure is diseased beyond salvage or poses an ongoing risk, such as malignancy or infection, that outweighs any benefit of preserving it.
Because Resection removes an entire body part rather than a portion of it, these procedures carry significant functional and cosmetic consequences, and they are typically followed by reconstructive or prosthetic planning as a separate consideration. The decision to resect is made only after other treatment options have been exhausted or are not viable given the severity of the underlying condition.
Anatomy & Axis Detail
Iris, Right
The iris of the right eye is the pigmented, muscular diaphragm that controls pupil size and regulates the amount of light entering the eye. Resection, or iridectomy, involves surgically removing a portion or the entirety of this tissue and is performed for indications such as angle-closure glaucoma requiring a peripheral iridectomy to relieve pupillary block, removal of an iris tumor like melanoma, or management of iris tissue damaged by trauma or chronic inflammation. Because the iris is thin and highly vascular, careful hemostasis is required during excision, and the resulting defect can alter pupil shape and light sensitivity, sometimes necessitating a cosmetic or prosthetic iris device afterward. The extent of tissue taken, whether a small peripheral segment or a larger sector, along with the underlying indication, should be clearly reflected in the procedural documentation.
Approach: Percutaneous
Percutaneous describes entry by needle or instrument puncture through the skin or mucous membrane to reach the site of the procedure, without cutting the tissue open or using a visualizing scope. It differs from Open in that the site itself is never exposed, and from Percutaneous Endoscopic in that no endoscope is used to see internal structures. Common examples include needle biopsies and injections.
Coding & Documentation
Coders assign Resection when the documentation confirms complete removal of an entire named body part, such as the whole eyeball in enucleation or the entire lacrimal gland, distinguishing it from partial excision procedures that would be coded as Excision instead. The operative note must clearly state that the entire structure was removed, not merely a lesion or portion of it, and coders need to identify the precise qualifying body part being resected.
A common error is applying Resection to biopsy or partial tumor excision cases where only a lesion or segment of tissue was removed, which actually falls under Excision; another is confusing enucleation, evisceration, and exenteration, three distinct eye removal procedures with different anatomic scope that require careful reading of the operative report to code correctly.