0CTN0ZZ
Resection Uvula 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 | N Uvula |
| 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
Uvula
The uvula is the small conical projection of muscle and mucosa hanging from the free edge of the soft palate, contributing to velopharyngeal closure during swallowing and to certain speech sounds. Complete resection, or uvulectomy, is performed for chronic uvular elongation causing snoring or airway obstruction, for uvulitis unresponsive to medical treatment, or as part of a broader palatal procedure such as uvulopalatopharyngoplasty for obstructive sleep apnea, though when performed as an isolated procedure it targets only this discrete structure. Because the uvula lies at the free margin of the soft palate, care is taken to avoid extending the resection into the palatal musculature itself, and documentation should confirm the uvula was removed in its entirety, distinguishing this from a partial trim, to justify coding it 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
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.