# Presentation: 356572

## Diagnosis Coding 

- September 28, 2007

- Diagnosis Coding
- For Staged Breast Reconstruction Encounters

**Notes:**
I want to talk to you about diagnosis coding
But that involves talking about procedures first

## Background 

- Background

- Breast reconstruction after mastectomy is typically staged, taking place over months or even years.  It can involve several or all of the following procedures:

- Some procedures are performed in separate encounters, others may take place during the same operative session.

- 	Insertion of tissue expander
- 	Breast mound reconstruction by tissue graft
- 	Removal of tissue expander
- 	Insertion of permanent breast implant
- 	Revisions to reconstructed breast
- 	Balancing procedures to native breast
- 	Nipple reconstruction
- 	Areolar tattooing

**Notes:**

To reconstruct the breast mound following mastectomy or other severe breast trauma, surgeons typically perform a breast implant, or a tissue flap, or a combination of the two. 

Implants are usually filled with either saline or silicone gel.  Immediate reconstruction may be performed at the same time as the mastectomy, if there is sufficient tissue in which to accommodate the implant.   Delayed reconstruction is performed when additional tissue must first be developed.  A tissue expander is placed in the chest wall and gradually filled at regular intervals to stretch out the skin.  Some expanders are designed to be left in place, but most are then removed and replaced with a permanent saline or silicone implant.

## Post-Mastectomy Tissue    

- Post-Mastectomy Tissue

- Which procedures a patient requires depends to some extent on how much tissue remains after mastectomy.

- skin sparing mastectomy...

- If there is sufficient tissue, immediate reconstruction may be performed by placing a permanent implant.  Or, if additional tissue is needed, a tissue expander may be placed or a graft may be performed.

- with tissue expander insertion

**Notes:**
That’s a “skin-sparing” bilateral mastectomy on right, the breast tissue is removed but the overlying skin is retained as much as possible
Left, tissue expander placed and closed, you can see the port in the lower chest

## Tissue Expanders     

- Tissue Expanders

- When additional tissue must first be developed, a tissue expander is placed in the chest wall and filled through a port at regular intervals to stretch out the skin.
- Some expanders are designed to be left in, but most are removed and replaced with a permanent implant.

**Notes:**
Delayed reconstruction is performed when additional tissue must first be developed.  A tissue expander is placed in the chest wall and gradually filled at regular intervals to stretch out the skin.  Some expanders are designed to be left in place but they say it doesn’t feel the same so most are then removed and replaced with a permanent saline or silicone implant.
Picture in right bottom corner is Mentor Spectrum, a combination tissue expander/permanent implant

That’s one way to develop additional tissue.  The other way is grafts.

## Tissue Grafts   

- Tissue Grafts

- TRAM graft

- latissimus dorsi graft

- Tissue grafts are used when more bulk is needed to reconstruct the breast mound.  A TRAM flap transfers tissue from the lower abdominal wall, a latissimus dorsi flap tissue from the back.
- Although the transferred tissue alone may be  sufficient, an implant can also be placed underneath.

**Notes:**
Tissue flaps, or grafts, are used when more bulk is needed.  A TRAM flap transfers skin and muscle from the patient’s lower abdominal wall.  Although this tissue is often sufficient to recreate the breast mound without an implant, an implant is also sometimes placed underneath.  A latissimus dorsi flap tunnels skin and muscle from the back to the chest, creating a pocket in which an implant can be placed.  Other types of grafts include the DIEP flap and gluteal flap.

First picture: Woman after mastectomy, showing trans–rectus abdominis muscle (TRAM) and surrounding tissues, in preparation for reconstruction.
A mastectomy site
B right trans rectus abdominis muscle
C left trans rectus abdominal muscle
D segment of abdominal tissues: skin and fat, to be transferred along with muscle to create the new breast

Second picture: Woman in process of trans–rectus abdominis muscle (TRAM) reconstruction.
A lines of reconstructed breast incisions
B right trans rectus abdominis muscle
C left TRAM muscle is swung over to re–create the new breast
D incision circle of re–positioned "belly button" incision
E line of abdominal surgery

## Exchange of Tissue 

- Exchange of Tissue
- Expander for Implant

- After the tissue expander has been fully expanded, it is removed and replaced by a permanent implant, typically during the  the same encounter.  Implants are filled with either saline or silicone.  Many models are available to try to match the patient’s natural contours.
- Because the expander is a foreign body, it’s normal for a capsule to form around it in the breast.  Adjustments to the capsule are often necessary to seat the permanent implant properly.

**Notes:**
Picture on top is Mentor MemoryGel saline implant moderate profile, next is high profile (note difference in both projection and base)
Third picture down is Mentor saline implant moderate profile, bottom is high profile

## Revision of Reconstructed Breast  

- Revision of Reconstructed Breast

- It is not uncommon for the reconstructed breast to require  surgical revision at some point.   This can be necessary because of “contour deficits”, such as: irregularity or deformity in the reconstructed tissue; inadequate projection; and asymmetry or disparity with the native breast.
- Surgeons are usually adamant that these issues are in the nature of breast reconstruction and do not represent complications of the graft or implant.

- contour deficit

- asymmetry

**Notes:**
Upper right – contour deficit (actually caused by rippling of implant)
Bottom right – asymmetry of left reconstructed breast

Not complications – worth keeping in mind that there’s no point in creating a code that nobody will ever be allowed to use

## Revision for Complications 

- Revision for Complications

- Unlike contour deficits, asymmetry     and the like, capsular contracture is a complication of the implant.   A thin capsule forms around all implants.  Contracture is when the capsule thickens abnormally and forms scar tissue around the implant, becoming hard and painful.  Capsular contracture may require capsulotomy or capsulectomy of the reconstructed breast.

- Fat necrosis is a complication of TRAM flaps.  Fat within the flap becomes ischemic due to inadequate blood supply.  It hardens and must usually be excised.

**Notes:**
Picture – bilateral reconstruction, capsular contracture on left
It only happens ion people with an implant
Linda – talk about the capsule!  It’s normal to form one, may have to adjust it to get the permanent implant to seat properly
The capsule is heavily calcified (capsular contracture or encapsulation). This is a common complication in which the capsule calcifies and hardens. The implant becomes rock-hard and fixed 

## Balancing Procedures to Native Breast 

- Balancing Procedures to Native Breast

- As an alternate to revising the reconstructed breast, or sometimes in addition to it, procedures are also performed on the native breast.  This includes augmentation, reduction, and mastopexy of a smaller, larger or ptotic native breast for balance with the reconstructed breast.

- mastopexy of native breast

- reduction of native breast

## Nipple and Areolar Reconstruction 

- Nipple and Areolar Reconstruction

- Nipple reconstruction is usually performed via skin grafts.  Common techniques include the skate flap, top-hat flap, and star flap.  Nipple reconstruction is usually delayed for several months after breast mound reconstruction, to allow the new breast time to settle.
- Areolar reconstruction can also be performed by grafting, though tattooing is much more common.

**Notes:**
Skin grafts: Because it is a 2-dimensional structure, the areola usually does not pose the same degree of difficulty in reconstruction as the nipple. Time-honored methods of reconstruction included skin grafts obtained from the contralateral nipple-areola complex or the medial thigh-vulva area. These grafts are intended to provide pigmented tissue that closely resembles the native areola. Currently, with great improvements in tattoo technique and a seemingly endless variety of pigments available, it seems unjustifiable to expose a patient to the risks of possible donor site complications to obtain the same or less satisfactory results than those obtainable with tattooing.

## Diagnosis Coding

- What ICD-9-CM diagnosis codes should be assigned at the different stages of reconstruction?

- 611.8			other breast disorder
- V45.71		acquired absence of breast
- V51 				aftercare involving plastic surgery
- V52.4			fitting and adjustment of breast 						prosthesis and implant

- It’s usually clear when to assign diagnosis codes for breast cancer as well as for device and graft complications.  For the more routine staged procedures, diagnosis code options include:

- Each of the possible codes has drawbacks and issues.

**Notes:**
I’m not really sure what to do myself
Plus I see a lot of variation in my audits among different hospitals – I’ve seen all of these codes used at various points by various hospitals

## Issues in Diagnosis Coding

- 	can 611.8 can be assigned for reconstructed breasts?

- 	at what stage in the reconstruction process is code 	V45.71 no longer applicable?

- 	V51 is a non-specific code according to Official Guidelines

- 	what is the actual intent of V52.4?

- 	what code is appropriate for nipple reconstruction?

- 611.8			other breast disorder
- V45.71		acquired absence of breast
- V51 				aftercare involving plastic surgery
- V52.4			fitting/adjustment of breast prosthesis/implant

- 	what code is appropriate when balancing procedures 	are performed on otherwise healthy native breasts?

## One Possibility 

- One Possibility

- New and revised codes are being proposed to clarify the issues and promote consistency in diagnosis coding at all stages.

- 	Use V45.71 for all encounters in which the breast 	mound is still being reconstructed, eg. grafting, insertion 	of TE or implant, expander exchange for implant
- 	Use 611.8 plus V10.3 for subsequent revisions, eg. 	contour corrections, and for balancing procedures on 	the native breast
- 	Use V51 for nipple reconstruction
- 	Reserve V52.4 for elective implant exchange, eg. for     	a different material or size

## A Philosophical Note 

- A Philosophical Note

- The point of breast reconstruction following mastectomy is obviously not to restore function.   But it doesn't need to be.  The point of breast reconstruction is to make the patient whole again.

- It has only been within the last 20 years or so that breast reconstruction, including revisions and balancing procedures, has been consistently viewed as non-cosmetic.   In developing new and revised codes, we should be mindful not to inadvertently recreate barriers for breast cancer patients.

**Notes:**
s far as considering this cosmetic goes ... yes, it's sensitive, and with good reason.  Amy, I most respectfully and sincerely urge you not to continue along the line of thought above.  I started at Blue Cross in 1983.  The men who ran the company at the time thought this way too.  We denied claim after claim for women who were suffering because reconstructing a breast after cancer surgery was, to their minds, no different from a facelift.  This began to change when Blue Cross started to get female Medical Directors and female VPs.  It's true that the point of breast reconstruction is not to restore function.  But it doesn't need to be.  The point of breast reconstruction is to make the patient whole again after non-elective surgery.  That is no longer viewed as cosmetic by payors.  The last thing in the world this proposal should do is to inadvertently create barriers to coverage for breast cancer patients, after it took decades to eliminate those barriers.  If anything, we should be mindful with this proposal to make sure that that doesn't happen.