0CTW0Z2
Resection Upper Tooth to All 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 | W Upper Tooth |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | 2 All |
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
Upper Tooth
An upper tooth refers to any tooth situated in the maxillary arch, each anchored in its own alveolar socket by the periodontal ligament and composed of enamel, dentin, pulp, and root structures. Resection in this context means the complete removal, or extraction, of the tooth from its socket, performed for reasons such as severe decay, periodontal disease, fracture, impaction, or as part of preparation for prosthetic or orthognathic treatment. Because each tooth is a discrete anatomic unit, coding applies individually per tooth removed rather than to the dental arch as a whole. The maxilla's proximity to the maxillary sinus floor is a notable consideration for posterior upper teeth, since extraction there carries a recognized risk of oroantral communication that can affect surgical technique and postoperative care.
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: All
This qualifier indicates that every body part within a defined anatomic set, such as all vertebral joints in a region or all vessels of a type, was treated during the procedure. It is distinguished from Single and Multiple, which indicate that only one or some, but not all, of the set was addressed.
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.