An operative report describes removing an entire left kidney for disease. The surgeon’s narrative casually says “excised the kidney,” but the objective was complete removal of the body part. How should ICD-10-PCS root operation selection be approached?
Select an answer to reveal the explanation.
Short Explanation
PCS cares about what you were trying to accomplish, not the verb the surgeon tossed into the dictation. Taking out the whole kidney is Resection territory; Excision is for cutting out a piece. Read the objective, then pick the root operation.
Full Explanation
ICD-10-PCS guidelines require coding the root operation that corresponds to the objective of the procedure. Excision is cutting out or off a portion of a body part, whereas Resection is cutting out or off all of a body part. Coders must not rely solely on the surgeon’s informal verb when the documented objective clearly indicates complete removal. Accurate root-operation selection drives correct PCS code construction for facility reporting.