0CTJ0ZZ
Resection Minor Salivary Gland 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 | J Minor Salivary Gland |
| 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
Minor Salivary Gland
Minor salivary glands are the hundreds of small, unnamed secretory glands scattered throughout the submucosa of the lips, buccal mucosa, palate, and other oral sites, each producing a small volume of mucous or mixed secretion. Resection in this body part is reported when one of these individual minor glands, rather than a major named gland, is the specific target of removal, most often because it harbors a mucocele, a benign mixed tumor, or an adenoid cystic or mucoepidermoid carcinoma, tumor types disproportionately represented among minor salivary gland neoplasms despite their small size. Because minor glands are diffusely distributed rather than forming a discrete organ, the operative note typically identifies the anatomic site of the specific gland resected, and coders should use this body part only when the excised tissue is documented as an entire minor salivary gland rather than an adjacent mucosal lesion.
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.