Excision vs. Resection ICD-10-PCS

The focus of this coding tip is on the excision vs. resection ICD-10-PCS coding. This can be challenging for coders when trying to determine the appropriate root operation (objective of procedure) to use. Physicians are using excision/resection interchangeably within the documentation. It is the coder’s responsibility to determine what the physician performed based on the documentation in the record.


  • The root operation “excision” takes out some or all of a body part without replacement (some of a body part).
  • If the surgeon states “partial resection” the coder can correlate this to the root operation of “excision.” Be sure and read the entire operative note and review the pathology report for final code assignment.
  • Biopsies are coded to the root operation “excision” when the surgeon excises tissue with a sharp instrument (other biopsy approaches are extraction and drainage).

Examples of Excisions:

  • Excision/removal of inner or outer quadrant of the breast
  • Excision of upper pole of right kidney
  • Excision/removal of portion of the sigmoid colon
  • Excision of lesion of the left lobe of liver
  • Excision of single or isolated lymph node(s)


  • The root operation “resection” takes out some all of a body part without replacement (all of a body part…no portion of the organ left behind).
  • If ICD-10-PCS contains a specific body part for anatomical subdivision of a body part “resection” would be used when all of the body part is cut out or off. (Lobectomy of RUL of lung would be coded as a resection if all the RUL is removed, even though the entire right lung was not removed).

Examples of Resections:

  • Cholecystectomy (removal/resection of the entire gallbladder)
  • Mastectomy of left breast
  • LUL lobectomy
  • Sigmoidectomy (removal of the entire sigmoid colon)
  • Resection/removal of entire left lobe of the liver
  • One or more entire chains of lymph nodes is removed

ICD-10-PCS Official Guidelines for Coding and Reporting 2019
ICD-10-PCS Reference Manual
AHH Coding Clinic for ICD-10-PCS, First Quarter 2018 Page: 22

HIAlearn.com has over 200 courses accepted by AHIMA for CEUs, with a selection also accepted by AAPC. Topics range from the most challenging procedures in today's coding world to wider reaching concepts. We offer multiple training plans to fit your exact needs, whether you are a new or experienced coder. Join more than 1,600 HIAlearn users and subscribe today.

Large Intestine Excision Resection Coding ICD-10-PCS

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

Leave a Comment


    Related blogs from Industry News , Medical Coding Tips

    Coding and Reporting Personal and Family History i...

    As a coder, you may wonder why it is so impor...

    Procedures Performed Via Burr Hole

    With the implementation of ICD-10-PCS came mo...

    Sequencing of the Principal Procedure

    During reviews we notice there is often confu...

    Oct 11, 2023

    Query Tip: Avoiding a Leading Query – Don't Be Dir...

    "A leading query is one that is not supported...