INCISION VS EXCISION VS RESECTION

Cynthia Brown, MBA, RHIT, CCS

CyntCoding Health Information Services
Coding Yesterdays Nomenclature Today
 STANDARDIZED TERMINOLOGY
One 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
Knowing the Difference

EXCISION
INCISION

RESECTION

Will Result in Accurate ICD-10 PCS Coding

DEFINITIONS & EXAMPLES FOR ICD-9 PCS

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

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

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

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

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

Excision of Lesion or Tissue of

Posterior Resection of Rectum (48.64)
Diaphragm (34.81)
DEFINITIONS & EXAMPLES FOR ICD-10 PCS

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

Drainage of Cerebral Meninges, Open Percutaneous Removal Drainage Device,

(009100Z) RT Breast (0HPT30Z)

(ICD-10 PCS Standard Definition)

Excision is cutting out or off, without replacement of a portion of a body part.
Percutaneous Excision of Pituitary Gland
Open Excision of RT Breast (0HBT0ZZ)
(0GB03ZZ)

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

Percutaneous Endoscopic Resection

Open Resection Lung, RT (0BTK0ZZ)
Diaphragm, RT (0BTR4ZZ)
 COMPARISON/CONTRAST
PROCEDURE ICD-9 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.
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.
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.
ICD-10 PCS
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 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 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 Yesterdays Nomenclature Today

Cynthia Brown, MBA, RHIT, CCS

AHIMA Approved ICD-10 CM/PCS Trainer
CyntCoding Health Information Services
Phone: 404-992-8984/E-Fax: 678-805-4919
P.O. Box 3019
Decatur, GA 30031
cyntcoder@cyntcodinghealthinformationservices.c
om
www.cyntcodinghealthinformationservices.com
Coding Yesterdays Nomenclature Today
INCISION VS EXCISION VS RESECTION
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