Coding Tip of the Month – October 2018

The Third Q 2018 Coding Clinic (page 13) provided coding advice regarding a bilateral deep inferior epigastric artery perforator (DIEP) flap reconstruction. The patient was status post a right mastectomy with tissue expander in place and during this procedure the patient undergoes a prophylactic left mastectomy with the bilateral DIEP. Clarification was requested on whether:

  1. Should the harvesting of the DIEP flap be coded separately?
  2. Is a mastectomy with breast replacement/reconstruction analogous to joint replacement surgery, in which the resection of the joint is not coded separately?

The following codes were recommended for this scenario:

PCS Code Description
0HRV077 Replacement of bilateral breast using deep inferior epigastric artery perforator flap, open approach, for the bilateral DIEP flap reconstruction
0HTU0ZZ Resection of left breast, open approach, for the left mastectomy
0HPT0NZ Removal of tissue expander from right breast, open approach

Rationale:

  1. The harvesting of the DIEP flap is not coded separately as this information would not add value to the coded data. In this case, the “Replacement” code fully specifies the fact than an autograft was harvested, with the qualifier value describing deep inferior epigastric perforator flap.
  2. Mastectomy with breast replacement/reconstruction and joint replacement surgery are conceptually very different. In joint replacement, the objective is to restore function by replacing the joint. For a mastectomy with reconstruction, it is important to identify that the primary objective of the surgery is to remove cancerous or potentially cancerous breast tissue, and that the reconstruction is an additional objective.

Shortly after the Coding Clinic was published, an article by Lynn Kuehn “ICD-10-PCS: The Rules Matter!” was published by Libman Education and discussed the confusion created by the codes recommended in the Third Quarter Coding Clinic. The focus of her discussion was on the importance of adhering to the hierarchy of coding guidance and that the root operation Replacement includes removing, physically eradicating or rendering nonfunctional the native body part being replaced.

These two divergent recommendations result in a discrepancy in the codes reported for cases where Resection of the breast occurs prior to Replacement of the breast in the same operative episode. I anticipate there will be forthcoming discussion of this controversy in the Coding Clinic as well as other sources so careful documentation and monitoring of this issue is recommended.

Consistency is a vital characteristic of data quality therefore coding professionals must immediately adopt and follow a guideline to ensure the codes reported in this scenario are consistent throughout the entire organization. Failure to research and adopt an official internal facility guideline will most certainly result in some cases being reported with a code for resection of the breast and others without the resection code.

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