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.

Excision:

• 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)

Resection:

• 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

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References:
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

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.