08TV3ZZ
Resection Lacrimal Gland, 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 | V Lacrimal Gland, 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
Lacrimal Gland, Right
The right lacrimal gland sits in the superolateral orbit and produces the aqueous component of tears, and resection of it - partial or complete - is performed for gland tumors, most notably pleomorphic adenoma or adenoid cystic carcinoma, or occasionally for severe inflammatory disease unresponsive to other treatment. Because the gland is functionally important for ocular surface lubrication, surgeons weigh the risk of chronic dry eye against the need for oncologic clearance, and complete gland resection for malignancy differs from lobe-sparing approaches used for benign lesions. Documentation should specify that gland tissue itself, not merely a duct or surrounding orbital fat, was excised, since lacrimal gland tumors often require orbitotomy for adequate access and the extent of resection has direct implications for postoperative tear production.
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.