0UT98ZZ
Resection Uterus to No Qualifier with No Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | U Female Reproductive System |
| Operation | T Resection |
| Body Part | 9 Uterus |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| 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 female reproductive organ or defined anatomic part, without any replacement. Hysterectomy, salpingectomy, and oophorectomy are the procedures patients most commonly associate with this family, performed for conditions ranging from cancer and fibroids to endometriosis, chronic pain, or as a preventive measure against hereditary cancer risk.
Because Resection means the entire body part is taken out rather than a portion of it, the distinction from partial removal matters clinically and surgically. A total hysterectomy removes the whole uterus, while a partial or supracervical hysterectomy leaves the cervix behind, changing both the postoperative anatomy and the code assigned. The approach used, open abdominal, laparoscopic, robotic-assisted, or vaginal, also affects surgical planning and recovery but is captured separately from the root operation itself.
Anatomy & Axis Detail
Uterus
The uterus is the muscular, pear-shaped organ that houses a developing pregnancy and sheds its endometrial lining during menstruation. Complete resection, or hysterectomy, is performed for symptomatic leiomyomas, adenomyosis, abnormal uterine bleeding refractory to conservative treatment, uterine or cervical malignancy, or severe prolapse, and the specimen may be removed through an abdominal, vaginal, or laparoscopic approach depending on uterine size and the indication. Whether the cervix is removed with the corpus (total hysterectomy) or left in place (supracervical hysterectomy) matters for documentation, since a supracervical procedure would not be captured under this body part value alone. The uterine vessels, cardinal ligaments, and cornual attachments to the fallopian tubes must all be divided to free the organ.
Approach: Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening Endoscopic describes instrumentation introduced through a natural orifice or a surgically created opening while using an endoscope for visualization, as in a routine colonoscopy performed through the anus. It differs from the plain Via Natural or Artificial Opening value by the added scope, and from Percutaneous Endoscopic by using an existing passage rather than a new skin puncture.
Coding & Documentation
Coders assign Resection when the operative note confirms an entire organ or anatomically whole body part was removed, such as total hysterectomy, bilateral salpingo-oophorectomy, or complete cervical excision. The pathology report and operative note together should confirm what specifically was taken, since PCS body part values distinguish between the uterus, cervix, ovaries, and fallopian tubes as separate structures each requiring their own code when removed.
A common error is coding a single combined value when bilateral organs are removed through separate steps, or failing to code each structure that was resected individually, such as coding only the hysterectomy and overlooking a concurrent oophorectomy. Coders should also watch for cases described as "debulking" or "cytoreduction," which may include a mix of Resection and Excision depending on whether entire organs or only portions of tissue were removed.