Coder Q&A with Pat Macc: Procedure Coding for a Breast Procedure
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
A patient was admitted for infected/protruding tissue expander and underwent removal of the tissue expander and capsulectomy. The coder has assigned 0HPT0NZ Removal of Tissue Expander from Right Breast, Open Approach and 0HPT0JZ, Removal of Synthetic Substitute from Right Breast, Open Approach. I’m not sure if the synthetic substitute code is assigned for removal of the ADM? When you run capsulectomy through an encoder you do get 0HPT0NZ but I’m not sure why as the capsule isn’t a synthetic substitute. In any event, is 0HPT0NZ the correct code? I’m thinking instead of removal synthetic substitute from breast, should this be removal from chest wall as there isn’t any breast tissue? Would this be an Excision procedure instead of Removal?
Pre-Op Diagnosis Codes:
* Breast implant protrusion, initial encounter [T85.49XA]
Post-Op Diagnosis Codes:
* Breast implant protrusion, initial encounter [T85.49XA]
BREAST TISSUE EXPANDER REMOVAL,CAPSULECTOMY
Anesthesia: General via LMA, converted to ETT
Findings: Large area of skin loss over exposed ADM/tissue expander. Highly calcified capsule Skin unable to be approximated without tension.
EBL: less than 50 mL
Indications for Procedure: is a 44-year-old female with a history of right-sided breast cancer s/p mastectomy with contralateral prophylactic mastectomy with reconstruction via placement of tissue expanders. They were never replaced with permanent prostheses. She had chemoradiation at that time. Recently, she has been found to have metastatic disease and is undergoing chemotherapy. About 1 week ago, she developed an area of erythema along her right breast. This progressed and she was eventually admitted for IV antibiotics on 5/21. The wound opened up and I was consulted for plastic surgical opinion on 5/25. On my initial exam, there was a large area of skin loss centrally on the breast with exposure of the tissue expander. I discussed at length with the patient and her husband regarding the need for removal of the expander in order to remove source of infection. We discussed risks, benefits, and alternatives including, but not limited to, the following: pain, bleeding, infection, delayed wound healing, and need for further procedures. They understood and wished to proceed. Informed consent was obtained.
Procedure in Detail: The patient was properly identified in the preoperative holding area and the right breast was marked to confirm site and side of procedure. The patient was then taken to the operating room and placed supine on the operating room table. All pressure points were padded. General anesthesia via LMA was then induced. The right breast was then prepped and draped in the usual sterile fashion. Surgical timeout was performed to confirm site and side of procedure.
Attention was turned towards the right breast. Again, a large area of skin loss was noted centrally with what appeared to be remnants of ADM present. Exposed tissue expander was also clearly seen. The ADM and continuous anterior capsule were carefully dissected free from the mastectomy flaps and excised. It was heavily calcified. A portion of this was sent for culture and for pathologic examination. An intact tissue expander was then removed and also sent for pathologic examination. A culture swab was taken of the pocket. The pocket was then copiously irrigated with nearly a liter of warm saline solution. Attempts were made to approximate and close the skin, however there was little elasticity to the skin and the edges were unable to be brought together. The wound was then packed with a saline-moistened kerlix and covered with several ABD pads. Patient was sent to recovery room”
I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
“Acellular dermal matrices are biologic materials, typically of human, bovine, or porcine origin. This tissue is processed to remove cells as well as any antigenic components to prevent an immune reaction, resulting in a dermal matrix that is composed of proteins such as collagen, elastin, hyaluronic acid, fibronectin, and proteoglycans. This matrix then serves as a scaffold for tissue ingrowth and revascularization by the host following implantation, during a process that can take several weeks” per https://www.nursingcenter.com/cearticle?an=00006527-201507000-00010&Journal_ID=496448&Issue_ID=3183560 With increasing frequency, surgeons are electing to use acellular dermis to assist with tissue expander or implant-based primary breast reconstruction.
I would not use the chest or skin section code here even if the breast had been removed previously. Since the tissue expander is functioning as a “breast” so to speak, it would be coded in the body site of breast for any procedures. Refer also to AHA Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018: Page 13. As for the ACM removal, that was placed to help serve as scaffold for tissue ingrowth, and this tissue is essentially acting as “Breast” tissue. For that reason, I would assign the code that is for right breast rather than skin of chest wall, 0HPT0KZ as stated above. Although in AHA Coding Clinic Fourth Quarter 2013, page 107, the initial insertion of ACM is not coded, I think that since the surgeon is having to remove the ADM remnants, that code 0HPT0KZ is warranted. I also think this code would include any calcified areas removed attached to the ADM.
We know that every case is unique. The above post is simply our opinion based on the information we have received. We encourage readers to research subsequent official guidance in the areas associated with this topic as they can change rapidly.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
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