INCISION VS EXCISION VS RESECTION

Cynthia Brown, MBA, RHIT, CCSCyntCoding Health Information Services

Coding Yesterday’s Nomenclature Today®

STANDARDIZED TERMINOLOGYOne of the supposed drawbacks of the ICD-9 CM/PCS nomenclature is its lack of standardized terminology. Standardized terminology is a universal language designed to be shared and recognized by users. In the health care setting, standardized terminologies are crucial for the accurate documentation of patient care and outcomes. Likewise, for accurate coding and reimbursement the coding nomenclature must also be standardized. Coding is essential for the capturing of standards of care, influencing policy, and funding services; therefore standardized terminology in coding is a must. Some of the benefits of standardized coding terminology are:

– Increased reimbursement for services– Decreased Third Party claim rejections– Decreased compliance issues– Decreased inefficient coding practices– Increased ability to track services and diseases for research– Increased ability to share data– Increased consistency in educational guidelines for coding

Will Result in Accurate ICD-10 PCS Coding

RESECTION

INCISION

EXCISION

Knowing the Difference

DEFINITIONS & EXAMPLES FOR ICD-9 PCS

Resection is the surgical removal of part of an organ or structure. (Merriam-Webster)

Posterior Resection of Rectum (48.64) Excision of Lesion or Tissue of Diaphragm (34.81)

Excision is the surgical removal or resection of a body part. (Merriam-Webster)

Excision or Destruction of Breast Tissue (85.20) Excision of Lesion of Thyroid (06.31)

Incision is a cut made into the body during surgery. (Merriam-Webster)

Incision of Cerebral Meninges (01.31) Reopening of Wound of Thyroid Field (06.02)

DEFINITIONS & EXAMPLES FOR ICD-10 PCS

Resection is cutting out or off, without replacement, all of a body part. (ICD-10 PCS Standard Definition)

Open Resection Lung, RT (0BTK0ZZ) Percutaneous Endoscopic Resection Diaphragm, RT (0BTR4ZZ)

Excision is cutting out or off, without replacement of a portion of a body part. (ICD-10 PCS Standard Definition)

Open Excision of RT Breast (0HBT0ZZ) Percutaneous Excision of Pituitary Gland (0GB03ZZ)

Incision is a cut made into the body during surgery. (Merriam-Webster)

Drainage of Cerebral Meninges, Open (009100Z)

Percutaneous Removal Drainage Device,RT Breast (0HPT30Z)

COMPARISON/CONTRASTPROCEDURE ICD-9 PCS ICD-10 PCS

INCISION Incisions are performed for several reasons (i.e., drainage of a site, exploration, insertion/removal of device, removal of solid matter, and reopening of operative site). The coder can usually find these procedures by going to the alphabetical index under incision and then the site of the incision.

The same procedures can be found in the Medical and Surgical Section; then by locating the Body System and referring to the particular Root Operation (i.e., Drainage, Inspection, Insertion/Removal of device, Extirpation). Incisional procedures must be found using their root operation rather than the term “incision.” For example, “drainage” for the “incision and drainage” of a site.

EXCISION Excision can mean both the partial and complete surgical removal of a body part. The removal of a lesion from a body part is considered a partial excision of a body part. On the other hand, the excision of the pituitary gland is the complete or total removal of the pituitary gland.

Excision means that only a portion of the body part is removed. The entire body part is NEVER removed when the root operation “excision” is used.

RESECTION Resection can mean both the partial and complete surgical removal of a body part. The alphabetical index tells the coder to “see also Excision, by site.”

Resection means that the entire body part is removed. The partial or excisional removal of a body part is NEVER appropriate when a resection is performed.

Coding Yesterday’s Nomenclature Today®

Cynthia Brown, MBA, RHIT, CCSAHIMA Approved ICD-10 CM/PCS TrainerCyntCoding Health Information ServicesPhone: 404-992-8984/E-Fax: 678-805-4919P.O. Box 3019Decatur, GA 30031cyntcoder@cyntcodinghealthinformationservices.com www.cyntcodinghealthinformationservices.comCoding Yesterday’s Nomenclature Today®

INCISION VS EXCISION VS RESECTION

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