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Assigning the correct ICD-10 PCS Root Operation for Resection or Excision of Lymph Nodes

Published on 

Tuesday, June 30, 2015

 | RAC Information 
 | FAQ 

Q:

During a procedure when only one or two lymph nodes are removed; would the correct “Root Operation” be “Resection” or “Excision”?

 

A:

Lymph nodes are known to form together in clusters, better known as a “chain of nodes”. There are generally numerous amounts of lymph nodes within a chain of nodes. It can be difficult to know for sure whether all nodes were removed or not during any one particular procedure. One example of this would be when a patient is extremely obese.

Assign root operation “Resection”:

  • When all nodes in a chain are removed.
  • When total removal of lymph nodes is the physician’s intent but difficult to determine if they have actually all been removed.

Assign root operation “Excision”:

  • When only a partial amount of lymph nodes are removed from the chain.

Assign root operation “Excision”:

  • Sampling of nodes removed – example would be Sentinel Nodes

The operative report should be read carefully to determine the exact intent for the lymph node removal.

References Coding Clinic 3rd Quarter 2014 (ICD-10-CM/PCS) pages 9 and 10

Article Author:

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.