Why is the root operation resection rather than excision? Understanding Medical Terminology

According to official ICD-10-PCS guidelines, a specific distinction dictates the correct surgical root operation. This guideline is essential for proper billing and record-keeping, clarifying why is the root operation resection rather than excision depending on whether a portion or the entirety of a body part is removed.

Quick Summary

The root operation is classified as resection instead of excision when the entire body part, or an anatomical subdivision designated as a body part in ICD-10-PCS, is completely removed without replacement. This contrasts with excision, which only involves removing a portion of a body part.

Key Points

• Definition of Resection: Resection is the removal of an entire body part, or an anatomical subdivision defined as a body part in ICD-10-PCS.

• Definition of Excision: Excision is the removal of only a portion of a body part.

• Anatomical Subdivisions: Certain lobes or regions (e.g., lung lobe) can be considered a full body part for coding purposes, making a lobectomy a resection.

• Documentation is Key: Coders must rely on operative notes and the official coding guidelines to correctly classify a procedure, even if the surgeon uses different terminology.

• Impact on Medical Records: The correct root operation classification ensures accurate billing, data collection, and patient record integrity.

• Coding System Specificity: The move to ICD-10-PCS increased the specificity of root operations, requiring precise differentiation between resection and excision.

• Reimbursement Effects: The choice between resection and excision can have an impact on insurance reimbursement for a procedure.

The Core Distinction in ICD-10-PCS

In medical coding, particularly within the ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System) framework, the definitions of 'excision' and 'resection' are precise and dictate how surgical procedures are classified. The primary difference lies in the extent of tissue removed during surgery.

According to official guidelines, resection is defined as the removal of all of a body part, without replacement. Conversely, excision is the removal of only a portion of a body part, without replacement. This distinction is critical for accurate coding.

The 'Entire Body Part' Rule

The classification of a procedure as a resection depends on whether the entire body part, as defined within the ICD-10-PCS tables, is removed. This definition can include specific anatomical subdivisions, such as a lobe of the lung, which are considered complete body parts for coding purposes. Therefore, removing an entire lung lobe is coded as a resection, even if the rest of the lung remains. Accurate coding requires consulting the operative report and the ICD-10-PCS tables.

Practical Examples of Resection vs. Excision

Here are some examples illustrating the difference:

• Hysterectomy: Removal of the entire uterus (including the cervix) is a resection. Removing only a part of the uterus is an excision.
• Lobectomy: Removing an entire lung lobe is a resection because the lobe is a defined body part in ICD-10-PCS. Removing only a portion of the lobe is an excision.
• Mastectomy: A total mastectomy removing the entire breast is a resection. A partial mastectomy removing only a portion is an excision.

The Importance of Documentation

Accurate coding relies heavily on the physician's operative report. Medical coders must interpret the report based on strict ICD-10-PCS definitions, even if the physician's clinical language differs. Correct classification is vital for proper billing, public health data, and accurate medical records.

Excision vs. Resection: A Comparison Table

Feature	Excision	Resection
Scope of Removal	Removes a portion of a body part.	Removes all of a body part or a defined anatomical subdivision.
Result	Part of the body part remains.	The designated body part is completely removed.
Key Consideration	Targeting a part of an organ or structure.	Removing an entire organ or defined subdivision.
ICD-10-PCS Guideline	Coded for removing a less specific portion.	Coded for removing all of a body part or its defined subdivision.
Example	Partial mastectomy.	Total mastectomy.

The Role of ICD-10-PCS in Surgical Classification

ICD-10-PCS provides a detailed system for classifying surgical procedures through defined root operations. These definitions ensure consistency in describing procedure objectives across different healthcare settings. The move from ICD-9 to ICD-10 brought increased specificity, emphasizing the importance of detailed documentation and precise root operation selection.

Conclusion

Understanding the specific definitions of resection and excision within ICD-10-PCS is fundamental for accurate medical coding. The key difference lies in removing a portion (excision) versus the entirety of a body part or defined anatomical subdivision (resection). This technical distinction is crucial for accurate billing, data collection, and patient records. Accurate coding requires careful review of operative reports and adherence to the official guidelines, highlighting the vital role of medical coders in healthcare. For detailed guidance, consult the official Centers for Medicare & Medicaid Services ICD-10-PCS guidelines.

Frequently Asked Questions

What is the simplest way to remember the difference between resection and excision?

A simple mnemonic is to think of "excision" as taking a piece "out" of something, and "resection" as taking the "entire" body part. If a portion is removed, it's an excision. If all of it is removed, it's a resection.

Can a surgeon's documented word for a procedure be incorrect for coding?

Yes. A surgeon may use clinical terminology that differs from the specific definitions in the ICD-10-PCS coding guidelines. A medical coder must read the full operative report to understand the extent of the procedure performed and apply the correct root operation.

Is a partial mastectomy an excision or a resection?

A partial mastectomy, where only a portion of the breast is removed, is coded as an excision. A total mastectomy, which removes the entire breast, is a resection.

Why does ICD-10-PCS classify a lung lobectomy as a resection?

A lung lobectomy is considered a resection because the ICD-10-PCS coding tables define specific lobes of the lung as their own body parts. The removal of the entire lobe therefore constitutes the removal of an entire 'body part' according to the coding system.

What happens if an excision is mistakenly coded as a resection?

Incorrect coding can lead to a number of problems, including inaccurate patient records, incorrect billing and reimbursement, and flawed public health data collection. It can also cause issues with hospital compliance and reporting.

Does the reason for the surgery (e.g., cancer vs. benign tumor) affect the root operation?

The reason for the surgery does not determine the root operation. The root operation is based purely on the objective of the procedure itself—what was done, not why it was done.

Do all ICD-10-PCS procedures have such specific definitions?

Yes, all root operations within ICD-10-PCS have strict definitions that medical coders must follow. This standardized approach is designed to provide consistency and accuracy in surgical classification across the board.