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Resection Nipple, Right to No Qualifier with No Device, External Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | H Skin and Breast |
| Operation | T Resection |
| Body Part | W Nipple, Right |
| Approach | X External |
| 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 on the skin and breast involve cutting out an entire body part rather than a sample or lesion. In this family, that most often means a mastectomy for breast cancer, or occasionally full-thickness removal of skin over a defined region, such as the entire nipple-areolar complex. The defining feature is completeness: the surgeon takes the whole named structure, not a margin around a mass.
These operations are done when disease, most commonly malignancy, has progressed to the point where partial removal would leave unacceptable risk of recurrence, or when the anatomy itself is being eliminated for prevention, such as a prophylactic mastectomy in a patient with a strong genetic predisposition. Reconstruction, if performed, is coded separately as its own procedure.
Recovery and follow-up depend heavily on what was resected and why, but the shared thread is that the tissue removed does not grow back and no portion of the original structure remains in that location.
Anatomy & Axis Detail
Nipple, Right
Resection of the right nipple refers to complete removal of the nipple-areolar complex on that side, which occurs as part of a standard (non-nipple-sparing) mastectomy, or independently when disease is localized to the nipple itself, such as Paget disease of the breast, which characteristically presents with eczematous change confined to the nipple-areolar skin. Because the nipple-areolar complex contains specialized ductal openings and pigmented skin distinct from the surrounding breast, its removal can be documented separately from resection of the underlying gland when coding requires that level of specificity. Reconstructive nipple creation performed later, using local flaps or grafts, is a distinct procedure from this resection and is coded separately. Surgeons note whether removal was isolated or part of a broader mastectomy.
Approach: External
External approach applies to procedures performed directly on the skin or mucous membrane, or on an accessible body surface, without any instrumentation passing through a puncture or orifice. It covers things like manual reduction of a fracture or excision of a skin lesion. It differs from Via Natural or Artificial Opening in that no internal passage is entered at all, only the exposed surface.
Coding & Documentation
The operative note must state that the entirety of the body part, such as the whole breast, was removed, not just a nodule or wedge. Pathology confirming a full specimen and the surgeon's language describing complete removal are what supports Resection over Excision.
The most common assignment error is choosing Resection when the documentation actually describes a partial procedure, such as a lumpectomy or partial mastectomy, which is coded to Excision instead. Coders also sometimes miss that skin resections are distinct from breast resections at the body part level, even though both fall under the same root operation, so the correct body part character still has to reflect exactly which structure, left or right breast, or a specific skin region, was taken.