FY 2024: MDC 9 - Diseases of Skin and Subcutaneous Tissue and Breast

Transcript

1. H I M | C O D I N G & C D I | H E A LT H I T | R E V C Y C L E Empowering Better Health e4health tackles healthcare’s data, quality and revenue challenges empowering your providers to focus on better care.
2. MDC 9 Diseases and disorders of Skin, Subcutaneous Tissue and Breast
3. Objectives • Review MDC 9- Diseases and disorders of skin, subcutaneous tissue and breast with a focus on selected diagnoses and procedures • Learner will acquire a basic understanding of the diagnoses and procedures included in MDC-9 • Discuss Query opportunities in MDC-9 • Review coding clinics relevant to the chosen topics in each DRG
4. MDC 9-MS- DRGs (Medical) • 592 SKIN ULCERS WITH MCC • 593 SKIN ULCERS WITH CC • 594 SKIN ULCERS WITHOUT CC/MCC • 595 MAJOR SKIN DISORDERS WITH MCC • 596 MAJOR SKIN DISORDERS WITHOUT MCC • 597 MALIGNANT BREAST DISORDERS WITH MCC • 598 MALIGNANT BREAST DISORDERS WITH CC • 599 MALIGNANT BREAST DISORDERS WITHOUT CC/MCC • 600 NON-MALIGNANT BREAST DISORDERS WITH CC/MCC • 601 NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC • 602 CELLULITIS WITH MCC • 603 CELLULITIS WITHOUT MCC • 604 TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC • 605 TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC • 606 MINOR SKIN DISORDERS WITH MCC • 607 MINOR SKIN DISORDERS WITHOUT MCC
5. MDC 9-MS- DRGs (Surgical) • 573 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC • 574 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC • 575 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC • 576 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC • 577 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC • 578 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC • 570 SKIN DEBRIDEMENT WITH MCC • 571 SKIN DEBRIDEMENT WITH CC • 572 SKIN DEBRIDEMENT WITHOUT CC/MCC • 579 OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC • 580 OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC • 581 OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/M • 582 MASTECTOMY FOR MALIGNANCY WITH CC/MCC • 583 MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC • 584 BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC • 585 BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
6. Ulcers Coding guidelines, clinical criteria and query opportunities
7. Pressure ulcer stages Guidelines Codes in category L89, Pressure ulcer, identify the site and stage of the pressure ulcer The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable
8. Unstageable Pressure ulcer stages Guidelines • Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation • These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft). This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.-- 9). • If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement
9. Documented Pressure ulcer stage Guidelines Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index Code assignment on pressure ulcer stage may be based on medical record documentation from “clinicians” other than the patient’s provider For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried
10. Patients with pressure ulcers documented as healed or healing • No code is assigned if the documentation states that the pressure ulcer is completely healed at the time of admission • NOTE: Healed ulcers are at a heightened risk of developing a new ulcer • Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record • If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage • If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider • For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission • NOTE: Documentation on ulcers is often conflicting, minimal, or unclear. For accurate code assignment, principal diagnosis selection, severity of illness/risk of mortality, and quality scores, careful review of documentation and clarification is essential
11. Patients admitted with pressure ulcer evolving into another stage during admission • If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: • One code for the site and stage of the ulcer on admission AND • A second code for the same ulcer site and the highest stage reported during the stay This Photo by Unknown author is licensed under CC BY-SA.
12. Pressure Ulcer Clinical concepts • Includes: • Bed sore, Decubitus ulcer, Plaster ulcer, Pressure area, Pressure-induced deep tissue damage, Pressure injury, Pressure sore, Pressure ulcer • Pressure ulcers develop when skin covering a weight bearing part of the body is compressed between bone and another body part or hard object • Pressure ulcers most commonly develop on ankles, heels, hips, knees, lower back, head and shoulder blades • The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. • Coding directives instruct to code first any associated gangrene
13. PRESSURE ULCER Query opportunities • Staging and laterality of a pressure ulcer may be based on medical record documentation from clinicians (e.g., nurses) who are involved in the care of the patient, but who are not the patient's physician/provider. However, the corresponding pressure ulcer diagnosis and location must be documented by the physician/provider. • If there is conflicting documentation in the medical record, either from the same clinician or from different clinicians, the patient's attending physician/provider should be queried for clarification • If a pressure ulcer progresses to a higher stage during the admission, a code for each stage would be assigned. For example, patient has a stage 1 ulcer of left buttock on admission and by discharge it is a stage 3. This example would be reported with two codes: one for the ulcer on admission: L89.321 for stage 1 ulcer with POA of yes and L89.323 for stage 3 ulcer with POA of “N”
14. PRESSUE ULCER DEFINITIONS The following are the clinical definitions of pressure ulcer/injury provided by the National Pressure Ulcer Advisory Panel (NPUAP): • Stage 1 Pressure Injury: Non-blanchable erythema of intact skin • May appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. • Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis • The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). • Stage 3 Pressure Injury: Full-thickness skin loss • Adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled or curled-under closed wound edges that may be dry, callused, or hyperkeratotic) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.
15. PRESSURE ULCER DEFINITIONS, CONTINUED The following are the clinical definitions of pressure ulcer/injury provided by the National Pressure Ulcer Advisory Panel (NPUAP) continued: • Stage 4 Pressure Injury: Full-thickness skin and tissue loss • With exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. • Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss • The extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. • If during the encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement (Official Coding Guidelines)
16. PRESSURE ULCER NOTES • In April 2016, the National Pressure Ulcer Advisor Panel replaced the term of pressure ulcer to pressure injury. The terminology more accurately describes the pressures injuries of both intact and ulcerated skin. There was confusion in the definitions for each of the stages which refer to injuries as "pressure ulcers". • Furthermore, Arabic numbers are now used in names of the stages instead Roman numerals. The term "suspected" has been removed from the Deep Tissue Injury diagnostic label. • If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement (Official Coding Guidelines). This Photo by Unknown author is licensed under CC BY.
17. Pressure induced deep tissue damage guidelines • For pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.--6) • Example code: • L89.026 Pressure-induced deep tissue damage of left elbow
18. DEEP TISSUE PRESSURE INJURY The following are the clinical definitions of pressure ulcer/injury provided by the National Pressure Ulcer Advisory Panel (NPUAP) continued: • Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration • Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface. • This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4). • Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. • Additional pressure injury definitions: • Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. • Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.
19. KENNEDY TERMINAL ULCER • Kennedy terminal ulcer (KTU) is a type of pressure ulcer that some individuals develop as they reach the end of life. KTUs are usually located on the sacrum or coccyx and are shaped like a pear, butterfly, or horseshoe. They have irregular borders and may be red, yellow, black, or purple in color. • The significant difference between KTUs and pressure ulcers is the suddenness of onset • KTUs may start out as what looks like an abrasion or blister on the skin and can progress to a stage 3 or 4 ulcer within a matter of hours. KTUs also start out larger and more superficial than other pressure ulcers, and develop rapidly in size, depth, and color. • They are more prevalent in the geriatric population • Treatment for these ulcers is the same as for any other pressure ulcer, depending on the severity, but may or may not be successful, dependent on the overall condition of the patient and the risk of mortality • Documentation of the rapid onset of the ulcer will be the key to identifying a KTU and will be evident by reviewing skin care documentation. Clinically it is a specific type of pressure ulcer by specific site and stage as documented. • Coding advice indicates KTU should be reported with the appropriate code from the pressure ulcer category based on documentation
20. Patients admitted with non-pressure ulcers documented as healed or healing guidelines No code is assigned if the documentation states that the non-pressure ulcer is completely healed at the time of admission NOTE: Healed ulcers are at a heightened risk of developing a new ulcer Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity If the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and severity of the non-pressure ulcer at the time of admission NOTE: Documentation on ulcers is often conflicting, minimal, or unclear. For accurate code assignment, principal diagnosis selection, severity of illness/risk of mortality, and quality scores, careful review of documentation and clarification is essential
21. Patient admitted with non-pressure ulcer that progresses to another severity during the admission Guidelines • If a patient is admitted to an inpatient hospital with a non-pressure ulcer at one severity level and it progresses to a higher severity level, two separate codes should be assigned • One code for the site and severity level of the ulcer on admission AND • A second code for the same ulcer site and the highest severity level reported during the stay
22. NON-PRESSURE CHRONIC ULCER Query opportunities • Skin ulcer is reported in combination with the following conditions and are assumed to be related unless the physician/provider clearly states the conditions are unrelated • Atherosclerosis of the lower extremities (MS-DRGs 299/300/301; MDC 5) • Chronic venous hypertension (MS-DRGs 299/300/301; MDC 5) • Diabetes (MS-DRGs 637/638/639; MDC 10) • Postphlebitic syndrome (MS-DRGs 299/300/301; MDC 5) • Postthrombotic syndrome (MS-DRGs 299/300/301; MDC 5) • Varicose veins (MS-DRGs 299/300/301; MDC 5) • An additional code for the severity of the ulcer is also reported Note: Coding Clinic 1st Quarter 2016 and the Official Coding Guidelines regarding "with" and 'in", allows an assumed causal relationship between diabetes and conditions listed in the Alphabetic Index as related to/due to diabetes.
23. DIABETIC ULCERS • Skin ulcers in diabetic patients are assumed diabetic in nature unless physician/provider clearly states the conditions are unrelated • Example 1: Patient admitted with ulcer and patient has diabetes. The diabetes with ulcer code would be sequenced as principal diagnosis with a code for the skin ulcer reported as a secondary diagnosis • Example 2: Patient admitted with an ulcer noted due to cellulitis by physician/provider and also has diabetes, with documentation from the physician/provider that the ulcer is not diabetic in nature. The ulcer code or code for cellulitis (depending on circumstances of admission) would be sequenced as the principal diagnosis and a code for diabetes with skin ulcer would not be reported. • Diabetic patient admitted with a skin ulcer. PDx: Diabetes with ulcer (MS-DRG 637/638/639, MDC 10) • Diabetic ulcer due to underlying diabetic neuropathy. PDx: Either Diabetes with neuropathy (MS-DRG 073/074, MDC 1) or Diabetes with ulcer (MS-DRG 637/638/639, MDC 10) • Sequencing depends on circumstances of admission • Diabetes with underlying peripheral vascular disease. PDx: Either Diabetes with peripheral angiopathy (MS-DRG 299/300/301, MDC 5) or Diabetes with ulcer (MS-DRG 637/638/639, MDC 10)
24. Skin Ulcers • Query opportunities • Acute renal failure • BMI less than 19.9, adult • Cellulitis • Hemiplegia as late effect of CVA • Malnutrition • Paraplegia • Pneumonia • Pressure ulcer stage 3 or 4 • Quadriplegia • Sepsis This Photo by Unknown author is licensed under CC BY-SA-NC.
25. Other skin conditions Coding guidelines, clinical criteria and query opportunities
26. Bullous pemphigoid Clinical concepts Skin condition with large, fluid-filled blisters that develop on areas of skin that often flex, such as the lower abdomen, upper thighs, or armpits Blisters may also develop in the mouth or other mucous membranes Is an autoimmune system reaction, sometimes triggered by certain medications, radiation therapy, and conditions such as psoriasis, diabetes, rheumatoid arthritis, ulcerative colitis, and multiple sclerosis, but the underlying cause is generally unknown Treatment is focused on healing the skin and relieving itching Query opportunities Documentation of underlying cause, if known Look for indications of any associated infection, such as sepsis, due to treatment with immunosuppressants
27. Erythema multiforme Clinical concepts  Includes:  Erythema multiforme major  Erythema multiforme minor  Stevens-Johnson syndrome  Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome (SJS-TEN)  Toxic epidermal necrolysis [Lyell]  If due to an adverse effect of drug, use an additional code to identify the drug. Query opportunities  Documentation must include any associated manifestations such as:  Arthropathy  Conjunctival edema  Conjunctivitis  Corneal scars and opacities  Corneal ulcer  Edema of eyelid  Inflammation of eyelid  Keratoconjunctivitis sicca  Mechanical lagophthalmos  Stomatitis  Symblepharon
28. ERYTHEMA NODOSUM Clinical concepts • An inflammatory disorder with presentation of red tender bumps under the skin (usually shins) with accompanying fever • Half the cases have an idiopathic origin with the other half being associated with infections, pregnancy, or drug sensitivity
29. HERPES ZOSTER • AKA: Shingles Clinical concepts • Review for any complications, manifestations or localized sites, such as: • Disseminated zoster • Encephalitis • Meningitis • Nervous system involvement • Ocular disease • Other complications Query opportunities NOTE: The MS-DRG assignment will be determined by the type of complication and may be in other MDCs
30. Lupus erythematosus Clinical concepts Includes: • Discoid • Subacute cutaneous • Other local If due to an adverse effect of drug, use an additional code to identify the drug Query Opportunities Review for organ involvement or manifestations in additional body systems for query opportunity for systemic lupus erythematosus (SLE). If SLE is documented, resultant assignment moves to different MS-DRGs (545/546/547)
31. Skin and breast neoplasms Coding guidelines, clinical criteria and query opportunities
32. Malignant melanoma Clinical concepts • Includes: • Melanocarcinoma • Melanoma in situ of skin • Melanoma NOS • Malignant melanomas are identified by specific site and laterality. • Malignant melanoma in situ is a new designation and also needs specific site and laterality Query opportunities • Clinically, when a melanoma has been resected/cured and the physician/provider documents recurrence of melanoma in a metastatic site such as lung, oncologists are indicating that the primary site is now active again • A query would be warranted to ensure physician/provider documentation is clear enough to support coding of primary site as well as all metastatic sites. Note: C43.1-, Malignant melanoma of eyelid, including canthus and D03.1-, Melanoma in situ of the eyelid, including canthus are assigned to MDC 2 Diseases and Disorders of the Eye
33. Merkel cell carcinoma • Neuroendocrine carcinoma of the skin originating in the Merkel cells (touch receptors) Clinical concepts • Review for presence of other sites of neuroendocrine tumors such as lungs, kidney, intestine, and liver Query opportunity
34. Breast cancer • Coding Concepts • Laterality (Right vs Left) • Sex (Male vs Female) • Location (Quadrant, Nipple, Areola) • Sample Code: • C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
35. Skin and breast neoplasms Query opportunities • Review for frequent secondary diagnoses, such as: • Acidosis • Acute renal failure • Cardiomyopathy and type • Cellulitis • Hyponatremia • Malnutrition and severity • Pneumonia and type • Sepsis • Thrush
36. Pediatric skin conditions Coding guidelines, clinical criteria and query opportunities
37. PEDIATRIC PRESSURE ULCERS • Pediatrics • Pediatric patients are at a higher risk for pressure ulcers than the adult population, especially in neonates with very immature skin and lack of subcutaneous tissue • Additionally, their pressure ulcers can appear within as early as 2 hours of admission with most common sites being the occiput and the ear • Studies indicate 50% of pressure ulcers in children are device related (e.g., gastrostomy tube bumper or O2 tubing) • Similar to the scale used to assess risk for developing a pressure ulcer, the Braden Q Score is for children and the Neonate Skin score for preterm infants • They measure risk in the same six categories as adults: sensory perception/neurologic deficits, mobility, activity level, exposure to moisture, nutritional status, and potential for friction/shearing and add a seventh component for oxygenation and perfusion of tissue
38. Stevens-Johnson syndrome In severe cases, severe gastrointestinal complications, diarrhea, renal, and hepatic damage may occur. Respiratory compromise may occur due to sloughing of the lining of the bronchopulmonary structures. It is diagnosed via noted involvement of mouth and eyes and via appearance of the skin lesions; however, a skin biopsy is sometimes obtained to rule out similar conditions. Stevens-Johnson syndrome (SJS) is a sudden, severe injury to the mouth, eyes, and skin where large quantities of mucosa or skin are destroyed and then sloughed off. This is a severe life-threatening condition requiring inpatient care. The occurrence of SJS is uncommon but occurs most frequently in toddlers, children, and adolescents. It is most commonly a result of a drug reaction, most frequently sulfonamides, anti-seizure medications, and analgesics. In some patients, SJS is secondary to infections such as pneumonias caused by mycoplasma. Bloody, crusty lips Mouth pain Halitosis Purple-red painful skin spots Photophobia Tissue death, blistering, and loss of skin surface area Conjunctival pus with possible scarring of eyelids Corneal erosions Shedding of fingernails Loss of skin pigment
39. Ritter’s disease • Staphylococcal scalded skin syndrome (SSSS), also known as Ritter's disease, is caused by exfoliative toxins from Staph aureus • A potentially fatal side effect of staphylococcal infection which occurs primarily in children under the age of 5 • Use additional code to identify percentage of skin exfoliation and infectious agent • SSSS usually affects newborns and children; adults are less commonly affected because they have improved renal function which allows for the clearance of these toxins from the body (adults with renal failure are more susceptible, however) • In newborns, the presentation of the disease usually occurs at age 3 to 7 days from birth • The infant is usually febrile and irritable and has diffuse blanching erythema usually beginning around the mouth. Blisters appear one to two days later, especially in areas of mechanical stress including areas where flexion occurs as well as buttocks, hands and feet. When gentle pressure is applied to the skin, it results in separation of the upper epidermis with wrinkling of the skin. Sometimes, the entire layer of the upper epidermis may shed. • Infants may have conjunctivitis and reddened mucous membranes. This process does not result in scarring. • Workup involves culturing of blood, urine, nasopharynx, umbilicus, skin, and any area suspected of being infected. A skin biopsy may be done. • The treatment for SSSS is the use of intravenous penicillinase-resistant penicillin, or vancomycin in the case of resistance or presence of MRSA. Skin care is provided with the use of emollients. Fluid and electrolyte replacement may be necessary due to loss.
40. Pediatric skin conditions Query opportunities • Review for frequent secondary diagnoses, such as: • Adverse effects of medications • Acute renal failure • Cellulitis • Hyponatremia • Malnutrition and severity • Pneumonia and type • Sepsis • Thrush • MRSA/MSSA infection
41. Breast conditions Coding guidelines, clinical criteria and query opportunities
42. Carcinoma-in-situ of breast Clinical concepts Intraductal carcinoma in situ Lobular carcinoma in situ Query opportunity Malignant neoplasm in situ of the breast is identified by specific morphology and laterality
43. Malignant neoplasm of breast Clinical concepts • Malignant neoplasm of the breast is identified by: • Specific site (such as nipple and areola, central, inner quadrant and outer quadrant) • Laterality • Male or female Query opportunity • Review for physician/provider documentation of all metastatic sites including: • Metastases to the lung, bone, brain or malignant ascites/pleural effusion • Sequela such as DVT and malnutrition Note: A closed biopsy of the breast is a non-DRG impacting procedure
44. Tamoxifen/raloxifene/arimidex Tamoxifen • Nonsteroidal antiestrogen antineoplastic agent • Can be used for either the treatment or prevention of breast cancer • The use of Tamoxifen can prevent breast cancer in patients who have no evidence of breast cancer but are at high risk of acquiring it Raloxifene • Approved by the FDA for treatment of osteoporosis in post-menopausal women • It is also approved for reducing breast cancer risk in this same group. Studies indicate it has equal success as Tamoxifen. • It is not indicated for treatment of active cancer but is a preventative therapy only Arimidex (anastrozole) • Another drug indicated for treatment of estrogen-dependent breast cancer and is an alternative to Tamoxifen • It is not currently indicated for the prevention of breast cancer • If Arimidex is being used to treat the patient's breast cancer, then assign the current cancer code. However, if the provider gives any indication that it is used as a preventative, then do not assign the current cancer code.
45. Coding a patient on tamoxifen • The coding of breast malignancy or history of breast malignancy can be challenging when a patient is on Tamoxifen. According to Coding Guidelines, if a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. • Therefore, if the patient is still under active treatment for malignancy of a primary site with treatment with radiation or chemotherapy, for example, retain the code for the malignancy of primary site. The patient would not be receiving radiation therapy or chemotherapy directed at the primary site unless further treatment were needed. • Because Tamoxifen can be utilized as a preventative therapy, it may not always be appropriate to assign a code for current cancer just because the patient is receiving Tamoxifen. Further information may be needed to make the determination. Current clinical practice advocates the use of Tamoxifen for up to 10 years post-cancer diagnosis instead of the previous recommendation of 5 years due to recurrence beyond the 5-year mark. • Examples: • A patient 10-years post mastectomy due to breast cancer is maintained on Tamoxifen for the treatment of the original cancer. Assign a current cancer code. • A patient 10-years post mastectomy for breast cancer is maintained on Tamoxifen for the prevention of metastatic cancer. Assign codes for use of selective estrogen receptor modulators (SERMS) and history of breast cancer codes. • A patient is maintained on Tamoxifen for the prevention of breast cancer because of a strong family history of breast cancer. Assign codes for use of selective estrogen receptor modulators (SERMS) and family history of breast cancer.
46. Tumor, Nodes and Metastases • TNM is a worldwide classification system used to identify solid tumors, associated lymphatic involvement, and metastases • T Tumor: The size/extent of the primary tumor • N Nodes: The number of regional lymph nodes affected • M Metastases: The presence or absence of metastases to other body sites/organs • T, N, and M describe a different area of cancer growth • Not used for blood-borne cancers such as leukemia or lymphomas • Higher values represent a greater extent of the cancer (i.e. Stage 1 represents the cancer has not spread; Stage 4 represents the cancer has spread to distant sites)
47. TMN staging system • Codes can be assigned based on documentation using the TMN staging system when authenticated by the attending. Coding Clinic, Second Quarter 2012 Page: 9 Question: A patient was admitted for Fletcher application. The diagnosis is documented as squamous cell carcinoma of the cervix with staging T4N1. Can a secondary code be assigned for lymph node metastasis based on the documentation provided? Answer: Based on the numerical/alphabetic designation (T4N1), assign code 196.6, Secondary and unspecified malignant neoplasm of lymph nodes, Intrapelvic lymph nodes. Coding Clinic, May-June 1985, page 6, states "if staging classes are being documented in the hospital medical record, the coding staff should obtain copies of the current classifications for use in decoding the numerical/alphabetic designations. The information obtained can be of assistance in the selection of ICD-9-CM codes relative to the presence of any secondary neoplasm." Refer to Coding Clinic, Second Quarter 2010, pages 7-8, for additional information on the use of the cancer staging form for assigning ICD-9-CM codes.
48. TMN staging system • Codes can be assigned based on documentation using the TMN staging system when authenticated by the attending. Coding Clinic, Second Quarter 2012 Page: 9 Question: A patient was admitted for Fletcher application. The diagnosis is documented as squamous cell carcinoma of the cervix with staging T4N1. Can a secondary code be assigned for lymph node metastasis based on the documentation provided? Answer: Based on the numerical/alphabetic designation (T4N1), assign code 196.6, Secondary and unspecified malignant neoplasm of lymph nodes, Intrapelvic lymph nodes. Coding Clinic, May-June 1985, page 6, states "if staging classes are being documented in the hospital medical record, the coding staff should obtain copies of the current classifications for use in decoding the numerical/alphabetic designations. The information obtained can be of assistance in the selection of ICD-9-CM codes relative to the presence of any secondary neoplasm." Refer to Coding Clinic, Second Quarter 2010, pages 7-8, for additional information on the use of the cancer staging form for assigning ICD-9-CM codes. Note: Although this is in ICD-9 convention, the coding clinic still currently applies in ICD-10-CM convention.
49. TNM Staging System
50. Breast Neoplasms Query opportunities • Review for frequent secondary diagnoses, such as: • Antineoplastic induced pancytopenia • Malignant pleural effusion • Malnutrition and severity • Metastasis to bone, brain, liver, lung • Pulmonary embolism This Photo by Unknown author is licensed under CC BY-SA.
51. Disorders of breast • Includes: • Abscess of areola, breast • Atrophy of breast • Granulomatous mastitis • Hypertrophy of breast • Hypoplasia of breast • Inflammatory disorders of breast • Lump in breast • Mammillary fistula • Mastitis • Mastodynia • Nipple discharge • Nodule in breast Query opportunities • These disorders in an antepartum, peripartum, or postpartum patient are assumed to be related to or complicating pregnancy and the pregnancy diagnosis would be sequenced as the principal diagnosis, moving the principal diagnosis to MDC 14 • The physician/provider must specifically indicate the condition is unrelated to the pregnancy to use these conditions as the principal diagnosis in a pregnant or postpartum patient
52. Benign mammary dysplasia • Includes: • Benign mammary dysplasia • Chronic cystic mastitis • Cystic breast • Fibroadenosis of breast • Fibrocystic disease of breast • Fibrosclerosis • Mammary duct ectasia • Solitary cyst of breast This Photo by Unknown author is licensed under CC BY.
53. Complications of breast prosthesis • Mechanical complications are specified as: • Breakdown • Capsular contracture of breast implant • Displacement • Leakage • Malposition • Obstruction • Perforation • Protrusion Query opportunity • Infection due to breast implant is assigned to code T85.79- in MS-DRGs 919/920/921 in MDC 21 Note: Breast implant associated anaplastic large cell lymphoma (BIAALCL) is a type of lymphoma that can develop around breast implants. Assign code C84.7A, Anaplastic large cell lymphoma, ALK-negative, breast. Do not assign a complication code in this circumstance, as per the Official Coding Guidelines. This Photo by Unknown author is licensed under CC BY.
54. Breast Conditions Query opportunities • Review for frequent secondary diagnoses, such as: • Acute blood loss anemia • Bacteremia • Cardiomyopathy • Cellulitis • Heart failure, acute and type • Pressure ulcer • UTI This Photo by Unknown author is licensed under CC BY-NC-ND.
55. Cellulitis and other skin conditions Coding guidelines, clinical criteria and query opportunities
56. Cellulitis • Documentation of specific sites and laterality will be required to appropriately classify cutaneous abscess, furuncle, carbuncle, cellulitis and acute lymphangitis. • Cellulitis: A non-necrotizing infection of the skin involving the deeper layer of the dermis and the subcutaneous fat but does not involve the fascia or muscle. It typically occurs as a result of the entry of bacteria through a breach in the skin barrier due to trauma (abrasion, laceration, insect bit, puncture wound), inflammation (eczema, radiation), pre-existing skin infections, and edema (lymphatic obstruction, venous insufficiency). However, a break in the skin may be so small as to be undetectable. The characteristic signs and symptoms of cellulitis include: • Localized pain, Swelling, Tenderness, Erythema, Warmth, Purulent drainage, Lymphangitis or regional adenopathy The most common bacteria associated with cellulitis are beta-hemolytic streptococci (groups A, B, C, G, and F) and S. aureus (including methicillin-resistant type) Treatment for cellulitis includes elevation of the affected body part, treatment of underlying conditions leading to cellulitis, and antibiotics. Inpatient admission for intravenous antibiotics therapy may be required.
57. Abscess, furuncle and Carbuncle • Documentation of specific sites and laterality will be required to appropriately classify cutaneous abscess, furuncle, carbuncle, cellulitis and acute lymphangitis • Skin Abscess: A collection of pus in the dermis and deeper tissues of the skin. A skin abscess appears as a painful, tender, fluctuant nodule that is usually pustular in nature. The abscess may spontaneously drain purulent material. There may be local adenopathy present as well. It would be unusual for the patient to exhibit signs and symptoms of systemic infection; however, it is possible for a bacteremia to occur. The infectious agent may be one or more organisms, with S. aureus causing between 25-50% of infections.13 • Furuncle: An infection of a hair follicle of the skin. Purulent materials extend down through the dermis and into the subcutaneous tissue which causes a small abscess to develop. Another name for a furuncle is a boil.13 • Carbuncle: A carbuncle is a fusion of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles. Furuncles and carbuncles develop when skin with hair follicles are exposed to friction and perspiration (typical areas include the back of the neck, face, axillae and buttocks). S. aureus (both methicillin-resistant and methicillin- susceptible) is the usual infectious agent. Treatment can range from warm compresses for small furuncles to incision and drainage for larger furuncles, carbuncles, and abscesses. Antibiotic prophylaxis may be administered as well especially if the organism is methicillin-resistant Staph aureus.
58. Cellulitis • Includes: • Acute lymphangitis • Carbuncle • Cellulitis • Cutaneous abscess • Furuncle • When patient has both cellulitis and acute lymphangitis of the same site, only a code for the cellulitis is assigned Query opportunities • Review for involvement of skin ulcer, sometimes called an "open wound." • Query for association with cellulitis and sequence based on treatment. If a patient is admitted with both cellulitis and skin ulcer and both conditions necessitated inpatient status, either condition may be sequenced as the principal diagnosis. • Review for associated signs of sepsis. Review to determine if cellulitis is associated with recent surgical incision or trauma.
59. Other local infection of skin/subcutaneous tissue Clinical concepts • Includes: • Cutaneous strongyloidiasis • Fistula of skin • Omphalitis not of newborn • Pyoderma • Pyogenic granuloma • Skin infection NOS This Photo by Unknown author is licensed under CC BY-SA-NC.
60. Lymphangitis Clinical concepts • Includes: • Chronic lymphangitis • Lymphangitis NOS • Subacute lymphangitis Query opportunity • Review the record to confirm the acuity of the lymphangitis. Acute lymphangitis is also assigned to this MS-DRG but to a different category code. This Photo by Unknown author is licensed under CC BY-SA.
61. Lymphangitis Query opportunity • Review for frequent secondary diagnoses, such as: • Acute renal failure • Chronic kidney disease and stage • Heart failure, acuity and type • Hyponatremia • Pneumonia and type • Pressure ulcer and stage • Sepsis • Skin Ulcer and type • UTI and causative organism
62. Candidiasis Query opportunity • Review for candidiasis in other locations such as oral, blood stream or genitourinary sources and review for treatment with Mycolog or Nystatin for query opportunity for candidal infection This Photo by Unknown author is licensed under CC BY-SA.
63. Dermatitis Dermatitis due to substances taken internally- Clinical concepts Includes: • Dermatitis due to ingested food • Dermatitis due to substances taken internally • Skin eruptions due to drugs taken internally Use an additional code for adverse effect, if applicable, to identify the drug Contact Dermatitis- Clinical concepts Includes: • Allergic contact dermatitis • Contact dermatitis • Irritant contact dermatitis Specific codes are available for the specific type of substance that caused the allergic or irritant contact dermatitis
64. QUERY OPPORTUNITY • Review for frequent secondary diagnoses that impact SOI/ROM such as: • Acute renal failure • AIDS/HIV disease • Cellulitis • Encephalopathy • Hyponatremia • Malnutrition • Pneumonia • Pressure ulcer • Secondary hyperparathyroidism • Sepsis • Urinary tract infection
65. ICD-10-PCS REview
66. ANATOMY REVIEW- SKIN and subcutaneous tissue
67. ANATOMY REVIEW- BREAST
68. SKIN • SKIN • Epidermis • No blood vessels • Receives nutrients from the basement membranes • Partial thickness—epidermis only • Dermis • Contains collagenous and elastic fibers • Small blood vessels, nerves, and hair follicles • Full thickness—epidermis and dermis • Subcutaneous tissue • Below the dermis, composed of adipose and connective tissue • Fascia • Below subcutaneous tissue, connective tissue covering connects subcutaneous tissue to muscle
69. Common root operations- SKIN Excision vs Resection •Medical reasons—Extraction •Cosmetic purposes—Alteration Liposuction Insertion •Excisional vs Non-excisional Debridement Reattachment and Reposition vs. Repair •Repair—similar procedures on the subcutaneous tissue and fascia •Insertion Reattachment and Reposition—Skin
70. Body part values for integumentary system • See Coding Guideline B4.6—if a procedure is performed on the skin, subcutaneous tissue, or fascia overlying a joint, the procedure is coded to the following body part: • Shoulder is coded to Upper Arm • Elbow is coded to Lower Arm • Wrist is coded to Lower Arm • Hip is coded to Upper Leg • Knee is coded to Lower Leg • Ankle is coded to Foot
71. Body part values for integumentary system • See Coding Guideline B3.5—if the root operations Excision, Extraction, Repair, or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded • Example: Excisional debridement that includes skin and subcutaneous tissue and muscle is coded to the muscle body part
72. Approaches For most skin/integumentary procedures • Open, Percutaneous • For Skin—External For procedures on the breast and nipple, mammary ducts • Via natural or artificial opening, via natural or artificial opening endoscopic Procedures on the subcutaneous tissue and fascia and breast—do not use External approach
73. Devices • Autologous tissue substitute • Tissue cultured epidermal autograft—from patient and grown in a laboratory to larger sized and used within approximately 14 days • Implantable devices in subcutaneous tissue and fascia • For example, contraceptive devices, stimulator generators, pacemakers, infusion pumps, tunneled VADs (vascular access device), totally implantable VADs
74. Totally implantable VAD • To access central veins • Device value W—Vascular Access Device, Totally Implantable • Inserted in subcutaneous pocket • If associated infusion device, coded separately to where the tip rests in 02H table Source: PanoramicTiger. 2009 (May). “Gripperneedle in a Port-A-Cath.” Digital Image. Wikimedia Commons. CC BY-SA 3.0. https://en.wikipedia.org/wiki/File:PAC_met_Gripper_erin.JPG.
75. Qualifiers • Types of flaps in Replacement procedures • Full thickness vs. partial thickness skin grafts • 3 full thickness if both epidermal and dermal layers • Partial thickness for tissue cultured epidermal autograft • Only dermis = partial thickness • Number of lesions destroyed • Transfer procedures in Subcutaneous Tissue and Fascia—more than one layer • May be described as pedicled perforator artery flap • Perforator artery and vein still attached TIP: When tissue flaps are coded with the root operation of Transfer, the body system value describes the deepest tissue layer in the flap. The qualifier is used to describe when more than one tissue layer is transferred.
76. Debridement • Excisional • Surgical removal or cutting away of tissue, necrosis, or slough. • Classified to the root operation “Excision” • May be performed by a physician or another health care provider • Involves an excisional as opposed to a mechanical (brushing, scrubbing, or washing) debridement • Uses a scalpel to remove devitalized tissue • Documentation of excisional debridement should be specific regarding the type of debridement • Query the physician if the documentation is not clear • Non-excisional • Involves the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, slough, or foreign material • Classified to the root operation “Extraction” (the “pulling or stripping out or off all or a portion of a body part by use of force”) except when performed by irrigating the tissue, which is coded to “Irrigation” in the Administration Section of ICD-10-PCS • Performed by a physician or other health care personnel • Versajet is an example of non-excisional debridement • Consists of an ultra–high pressure generator with a console and disposable attachments • A natural vacuum created by the jet stream removes tissue fragments • Specialized features allow physicians to debride traumatic wounds, chronic wounds, or other soft tissue lesions and to aspirate and remove contaminants or other debris • Another example of non-excisional debridement is ultrasonic debridement
77. Debridement • Excisional • May be performed on any body site and any location within the facility (in patient's room, holding area, operating room, or in a whirlpool in physical therapy) • Excised tissue does not need to go to pathology for an excisional debridement to be reported, provided the description of the procedure portrays an excision occurred • Non-excisional • May include: • Minor removal of loose fragments • Scraping away tissue with a sharp instrument • Whirlpool debridement • Digressive debridement with pulse lavage • Mechanical lavage • Pulsatile lavage • Mechanical irrigation • High-pressure irrigation • I&D • Debridement, NOS
78. Debridement Coding Clinic advice indicates that the phrase "debridement" alone is not sufficient to assign a procedure to the root operation of Excision • Documentation of sharp debridement only is not always indicative of excisional debridement • The description of debridement performed must be documented as definite cutting away of tissue before excisional debridement can be assigned Coding Clinic advice further states, "Clear and concise documentation is needed in order to accurately report excisional debridement" • "If the documentation is not clear or there is any question about the procedure, the physician/provider should be queried for clarification" Documentation of debridement needs to be descriptive enough to create a clear picture of procedure performed. Documentation should include: • Method of debridement: Should be descriptive, painting a clear picture of the type of debridement performed • Depth of debridement: Did the physician/provider debride beyond the dead or damaged tissue down to healthy, viable tissue? • Instruments used to perform the debridement: While the type of instrument used to perform the procedure is not the determining factor in deciding whether the procedure was excisional or non-excisional, the instrument used is one component that helps support the type of debridement reported. However, use of a sharp instrument does not always indicate that an excisional debridement was performed. Excisional debridement is reported when the physician/provider documents "excisional debridement" and/or the documentation meets the root operation definition of excision Documentation of the procedure must be in the body of medical record such as progress notes or operative report
79. Debridement query opportunity • Review documentation for depth of debridement and method or technique used to accomplish the debridement. If the documentation is not clear as to the type, depth of debridement, then query the physician/provider for clarification. • Excision debridement of skin (excision of skin) is an extremely rare procedure as typically the surgeon needs to debride down below the dermal layer Notes • Soft tissue is a part of the subcutaneous tissue and fascia body system • Coding Clinic 2020 2nd Quarter p. 19 clarified that for a chronic non-pressure ulcer documented as necrotic with exposed subcutaneous tissue, subcutaneous tissue includes the fat layer • Root operation "excision" is defined as "cutting out or off, without replacement, a portion of a body part"
80. Skin graft procedures Dermal regenerative graft Clinical concepts • Includes: • Artificial skin • Creation of "neodermis" • Integumentary matrix implant • Prosthetic implant of dermal layer of skin • Regenerate dermal layer of skin Notes • Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part"
81. Skin graft procedures •Clinical concepts •Typically, an autograft and includes all dermal layers •Documentation requirements/ query opportunity •Specificity is required to distinguish between full thickness and partial thickness. In addition, specificity is required to identify the tissue substitute used (e.g., autologous tissue, nonautologous tissue or synthetic substitute) •Notes •Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part" Full-thickness skin graft •Documentation requirements/ query opportunity •Specificity is required to distinguish between full thickness and partial thickness. In addition, specificity is required to identify the tissue substitute used (e.g., autologous tissue, nonautologous tissue or synthetic substitute) •Notes •Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part" Graft, skin
82. Skin graft procedures Pedicle grafts or flaps Clinical concepts • Includes: • Advancement of pedicle graft • Attachment of pedicle or flap graft to hand • Attachment of pedicle or flap graft to other sites • Revision of pedicle or flap graft • A pedicle graft is performed with the graft remaining attached to its vascular supply. Includes entire dermal layers • A flap graft can be either a pedicle graft or free flap. Includes all dermal layers • A rotating flap graft is a semicircular pedicle graft in which the flap graft rotates on a pivot point into an adjacent defect area Documentation requirements • Provider documentation needs to be specific as to graft being free or pedicle as well as specific to location of donor site Notes • Pedicle or flap grafts are reported using the root operation of "transfer" which is defined as "moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part." These are further identified by specific body system (skin or subcutaneous tissue and fascia) as well as specific body site.
83. Detachment • Includes amputation of: • Above knee • Ankle • Below knee • Foot • Toe Query opportunity • Amputation is reported using the specific body part removed, including laterality • Additional documentation should include specific site of amputation such as high, medium and low upper or lower leg. See definitions of amputation levels and MS-DRG assignment based on principal diagnosis selection in Quick Reference Guide Surgical References Section. Notes • Root operation "detachment" is defined as "cutting off all or part of the upper or lower extremities"
84. NON-OR procedures ▪ Insertion of totally implantable vascular access device (TIVAD) or tunneled catheter • Includes: • TIVAD • Tunneled access catheter • A TIVAD system differs from a tunneled catheter in that it is completely subcutaneous with all ports under the skin (e.g., Port-a-cath and Hemocath). The following catheters are classified as tunneled as they have an external port: Tessio, Ashsplit, Groshong, Hickman and Quinton. • There are unique codes for a TIVAD versus a tunneled catheter insertion. For each of these device insertions, an additional code would be assigned for the associated catheter insertion into the blood vessel with the location (body part) being the end point of the catheter. • Use ‘Insertion’ as root operation • Query opportunity • Documentation should include an indication the device was implanted under the skin, as well as the specific site and laterality of the insertion • Ensure operative/ procedure note includes documentation of location of both the subcutaneous portion as well as the vascular end point
85. Totally implantable VAD • To access central veins • Device value W—Vascular Access Device, Totally Implantable • Inserted in subcutaneous pocket • If associated infusion device, coded separately to where the tip rests in 02H table Source: PanoramicTiger. 2009 (May). “Gripperneedle in a Port-A-Cath.” Digital Image. Wikimedia Commons. CC BY-SA 3.0. https://en.wikipedia.org/wiki/File:PAC_met_Gripper_erin.JPG.
86. BREAST Procedures LUMPECTOMY- removes a small piece of breast tissue or ‘mass/lump’ • Partial- more than lumpectomy, but not total breast • Total/Simple- entire breast, no lymph nodes/muscle • Modified Radical- entire breast and axillary lymph nodes, no muscles • Radical—entire breast, axillary, infraclavicular and supraclavicular lymph node chains, and muscle from below the breast • Tissue-sparing mastectomy: Uses small incisions around the nipple or on the underside of the breast to access and remove tissue. This approach can result in a more natural-appearing reconstruction. • Skin-sparing mastectomy includes removal of breast tissue and the nipple but leaves the skin intact. • Breast reconstruction is performed during the same operative episode. • Nipple-sparing mastectomy is a relatively new technique that leaves the skin, nipple and peripheral breast tissue intact. The breast is then reconstructed with an implant or tissue transferred from another location on the body MASTECTOMY
87. Mastectomy Query opportunity • Ensure physician/provider documents all types of tissue resected or excised, if applicable. Each type of excised or resected is assigned a separate code. • Ensure physician/provider documents all types of tissue resected or excised such as lymph nodes or muscle • Possible structures also removed during mastectomy include: • Axillary lymphatic (left or right) • Internal mammary lymphatic (left or right) • Thorax muscle (left or right)
88. Mastectomy and Replacement • If mastectomy and replacement at the same operation, mastectomy is coded separately • See Coding Guideline B3.18 • Tissue expander insertion—not replacement • Injection port to allow addition of fluid • Tissue expander removed before replacement procedure Source: BruceBlaus. 2014 (January). “Breast Reconstruction–Expander.” Digital Image. Wikimedia Commons. https://en.wikipedia.org/wiki/File:Blausen_0138_BreastReconstruction_Expander.png.
89. Breast reconstruction ▪ Breast reconstruction may be performed at the same time as a mastectomy or at a later date ▪ Timing depends on the outcome of a physical exam by the plastic surgeon, the surgical risk factors such as smoking or being overweight, and treatments needed following the mastectomy ▪ Although a reconstructed breast may help the patient feel more comfortable with their appearance following a mastectomy, the reconstructed breast will not match the look or feel of a natural breast Techniques • Natural tissue flap is breast reconstruction using skin and soft tissue flaps from the patient's own body, resulting in a breast that mimics the look and feel of a natural breast better than a reconstruction with an implant • The most common natural flap procedures use the patient's own tissue from the abdomen or back but may also be taken from the buttocks or thigh. In some procedures, part or all of a muscle must also be transplanted to provide blood flow to the flap tissue. These techniques: • More complex and invasive, usually requiring a longer hospital stay and a longer recovery period • Leave scars in the donor tissue site
90. Breast replacement • Free flap or graft—Replacement • Multiple layers of tissue—reconnected to vascular supply • Deep Inferior Epigastric Perforator (DIEP) • Muscle Transfer—Flaps or pedicle flaps—Transfer • Body part—Abdominal Muscle R/L (what is moving) • Qualifier—Flap • Transverse Rectus Abdominis Muscle (TRAM) • Latissius Dorsi myocutaneous Flap
91. Types of breast reconstruction • Latissimus dorsi muscle (LDM) flap reconstruction in which an oval flap of skin, fat, muscle and blood vessels from the upper back is used to reconstruct the breast by moving the flap under the skin around to the chest. The blood vessels are left attached to their original blood supply in the back. This is considered a muscle-transfer type of flap and is performed in combination with an implant. • Fleur de lis myocutaneous flap is the same as the LDM but without the implant. • Transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast. It can be performed as either a pedicled flap (connections to native circulation remain intact) or as a free flap. A side benefit is stomach flattening. An implant may be needed if there is insufficient skin and fatty tissue in the lower abdomen to complete the reconstruction. • Deep inferior epigastric perforator (DIEP) flap uses skin and fatty tissue from the lower abdomen to reconstruct the breast. This procedure keeps the abdominal muscle intact and helps preserve abdominal strength. The tissue is separated from its native blood supply and is reattached to the internal mammary artery and vein and is shaped to create a new breast. • Superficial inferior epigastric artery (SIEA) flap uses skin, fatty tissue and blood vessels, including the superficial inferior epigastric artery from the abdomen to reconstruct the breast. This technique leaves all the muscles and most of the connective tissue of the abdomen intact, preserving abdominal strength. This can be important for women who are physically active. However, many women aren't eligible for an SIEA flap due to superficial blood vessels being too small to support the flap, the vessels may have been cut during a previous C-section or hysterectomy, or the vessels just do not exist.
92. Types of breast reconstruction • Gluteal artery perforator (GAP) flap uses skin and fatty tissue from the buttocks to reconstruct the breast. No buttock muscle is used, preserving gluteal function. This type of reconstruction may be a good option for women who have more fatty tissue in their buttocks area than in their abdomen. If there is a noticeable difference in buttock size following a GAP procedure, liposuction can be performed on the opposite buttock to create a more even look at a later time.21 • Superior GAP procedures use skin and fatty tissue from the upper part of the buttock • Inferior GAP procedures use skin and fatty tissue from the lower part of the buttock • Transverse upper gracilis (TUG) and diagonal upper gracilis (DUG) flap procedures use skin, fatty tissue and muscle from the upper inner thigh to reconstruct the breast. The gracilis muscle is used, whose natural function is to help bring the leg toward the body but is not a critical muscle hence most patients do not notice any significant weakness following the procedure. TUG or DUG flap procedures may be a good option for women with excess fatty tissue in their upper inner thigh area who are not good candidates for other flap procedures. • Profunda artery perforator (PAP) flap uses skin, fatty tissue and a blood vessel from the back of the upper thigh to reconstruct the breast. Because the amount of tissue available at the back of the upper thigh is typically limited, this technique works best for women with small breasts, or for those who are not good candidates for abdominal or other flap procedures.
93. Breast implants Breast implants • Root operation "alteration" is defined as "modifying the anatomic structure of a body part without affecting the function of the body part” (Always cosmetic) • Root operation "replacement" is defined as "putting in or on biological or synthetic material that physically takes the place and/or function of all, or a portion of, a body part" There are two basic types of breast implants, saline and silicone. In both, the outer covering is made of a solid form of silicone. The difference is in the substance used to fill the implant shell: • Saline implants are filled with saline and come deflated. During surgery, the shell is filled to the desired volume. • Silicone implants are filled with semi-solid silicone gel. These implants come pre-filled with the desired volume.
94. References ▪ AHA ICD-10-CM and ICD-10-PCS Coding Handbook ▪ ICD-10-PCS: An Applied Approach 2023 ▪ Cengage: 3-2-1 CODE IT! ▪ Kennedy Pressure Ulcer, Kennedy-Evans, K., http://www.kennedyterminalulcer.com/ ▪ Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis, High, W., and Roujeau, J., Last Updated: Aug 16, 2018, https://www.uptodate.com/contents/stevens-johnson- syndrome-and-toxic-epidermal-necrolysis-pathogenesis-clinical-manifestations-and-diagnosis?search=Stevens- Johnson%20syndrome%20and%20toxic%20epidermal%20necrolysis&source=search_result&selectedTitle=1~150& usage_type=default&display_rank=1 ▪ Vesiculobullous and Pustular Lesions in the Newborn, Pielop, J., last Updated Feb 28, 2018, https://www.uptodate.com/contents/vesiculopustular-and-bullous-lesions-in-the-newborn-and- infant?search=%20vesiculobullous-and-pustular-lesions-in-the- newborn&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
95. References ▪ https://blog.shyaway.com/what-are-breast-quadrants-and-how-does-cancer-affect-them/ ▪ Pressure Injuries - Dermatologic Disorders - Merck Manuals Professional Edition ▪ Complications of Diabetes Mellitus - Endocrine and Metabolic Disorders - Merck Manuals Professional Edition ▪ Systemic Lupus Erythematosus (SLE) - Musculoskeletal and Connective Tissue Disorders - Merck Manuals Professional Edition ▪ Tamoxifen for the prevention of breast cancer: Current status of the National Surgical Adjuvant Breast and Bowel Project P-1 study. Fisher B, Costantino JP, Wickerham DL, et al , Journal of the National Cancer Institute 2005; 97(22):1652-1662 ▪ Long-term effects of continuing adjuvant Tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. The Lancet, 2012 DOI: 10.1016/S0140- 6736(12)61963-1, Davies, et al., https://www.ncbi.nlm.nih.gov/pubmed/23219286
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