0TT00Z1
Resection Kidney, Right to Syngeneic with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | T Urinary System |
| Operation | T Resection |
| Body Part | 0 Kidney, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | 1 Syngeneic |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection removes an entire urinary organ or a complete anatomical segment of one, without replacing it with substitute tissue or material. Total nephrectomy for kidney cancer, complete cystectomy for invasive bladder cancer, and total removal of a diseased ureter are typical examples within this family.
These procedures are performed when disease - most often cancer, but sometimes severe infection or a nonfunctioning organ - affects an entire structure and cannot be adequately treated by removing only the affected portion. Because Resection takes the whole organ or whole anatomical segment, it is generally reserved for advanced or extensive disease rather than localized findings.
Patients undergoing these procedures often need additional reconstructive or diversion procedures afterward, such as creation of a urinary conduit following cystectomy, which are coded as their own separate procedures.
Anatomy & Axis Detail
Kidney, Right
The right kidney is a paired retroperitoneal organ responsible for filtering blood and producing urine, and Resection here means the entire organ is surgically removed, distinguishing it from partial nephrectomy procedures that excise only a portion. A complete right nephrectomy is performed for renal cell carcinoma confined to one kidney, a nonfunctioning kidney from chronic obstruction or infection, severe trauma with uncontrollable hemorrhage, or as the donor procedure in living kidney transplantation. The right renal vein's shorter course and its proximity to the vena cava, along with the liver overlying the surgical field, make right-sided nephrectomy technically distinct from the left-sided operation and often influence whether an open, laparoscopic, or robotic approach is chosen. Documentation should confirm that the entire kidney was removed, since any remaining renal tissue would instead point toward an excision procedure.
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.
Qualifier: Syngeneic
This qualifier denotes a syngeneic tissue substitute, sourced from a donor who is genetically identical to the recipient, such as an identical twin. It is a narrower category than the allogeneic qualifier, which covers any same-species donor regardless of genetic match, and is distinguished from zooplastic tissue, which comes from another species.
Coding & Documentation
Coders need documentation confirming that an entire organ or an entire anatomically distinct segment - a whole kidney, a whole ureter, or the entire bladder - was removed, not just a portion of it. The pathology and operative reports together should establish the extent of what was taken, since removal of only part of a segment falls under Excision instead.
The most common assignment error is applying Resection to a partial nephrectomy or partial cystectomy, which are Excision because tissue remains behind. Coders should also separately capture any reconstruction, diversion, or replacement procedure performed in the same session, since those are not bundled into the Resection code itself.