0BTC0ZZ
Resection Upper Lung Lobe, Right to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | B Respiratory System |
| Operation | T Resection |
| Body Part | C Upper Lung Lobe, Right |
| 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
Resection describes the complete surgical removal of an entire respiratory structure without replacing it, and in this body system it most often refers to pneumonectomy, the removal of an entire lung, most commonly performed for lung cancer that cannot be controlled with a smaller resection. It also covers total removal of a lobe when the whole lobe is taken, though partial lobe removal is classified differently.
These are major operations reserved for situations where disease, most often malignancy but sometimes severe infection or destroyed lung tissue, involves an entire anatomically distinct structure, making anything less than complete removal insufficient. Patients undergoing these procedures typically face a lasting reduction in lung capacity, so candidacy is carefully weighed against overall lung function beforehand.
Anatomy & Axis Detail
Upper Lung Lobe, Right
The right upper lobe is the smallest of the right lung's three lobes, sitting above the horizontal fissure and supplied by its own segmental bronchi and pulmonary vessels. Resection, or lobectomy, of this lobe is one of the most frequently performed major lung operations, most often undertaken for non-small cell lung cancer confined to the lobe, since its distinct fissural boundaries and independent blood supply allow it to be removed while leaving the middle and lower lobes intact. The proximity of the upper lobe's vessels and bronchus to the mediastinum and hilum means careful individual ligation of the pulmonary artery branches, vein, and bronchus is required. Documentation should confirm that the entire lobe, not merely a wedge or segment, was excised to support coding this procedure as a resection.
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
The operative report must clearly state that an entire named anatomical unit, a whole lung, a whole lobe, or the whole trachea, was removed, since ICD-10-PCS Resection requires completeness of that structure. A frequent coding error is applying Resection to a lobectomy when only part of a lobe was actually removed, or applying it to a wedge resection of lung tissue, both of which should be coded as Excision because they remove only a portion of the body part.