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Code This!

Scenario Week of November 13, 2014:
View Current Scenario

Assign the correct ICD-10-CM diagnosis and ICD-10-PCS procedure codes for the following inpatient coding scenario:

PREOPERATIVE DIAGNOSIS: Right breast carcinoma

POSTOPERATIVE DIAGNOSIS: Right breast carcinoma, prophylactic removal of left breast

PROCEDURE PERFORMED: Bilateral mastectomy with bilateral free TRAM flaps


INDICATION FOR SURGERY: The patient is a 53-year-old woman, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor, and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. This apparently was positive in two separate locations within the suspicious area. She also underwent MRI, which suggested that there was significant size to the area involved. Her contralateral left breast appeared to be uninvolved.

We discussed right mastectomy with TRAM flap breast reconstruction and she prefers this option in order to avoid the need for an implant. We discussed the pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself. Due to the invasive nature of the right breast carcinoma, she wishes to have prophylactic removal of her left breast as well. A TRAM flap will also be used to reconstruct the left breast.

DESCRIPTION OF SURGERY: The patient was taken to the operating room. She underwent general endotracheal anesthetic. TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's bilateral anterior chest wall, neck, axilla, and right and left arms were prepped and draped in the usual sterile manner. Starting with the right breast the recent biopsy site was located in the upper and outer quadrant of the right breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally toward the latissimus dorsi, rectus abdominis fascia. Following this, the breast tissue along with the pectoralis major fascia was dissected off the pectoralis major muscle. The dissection was started medially and extended laterally toward the left axilla. The breast was removed. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. The same procedure was done on the left side.

At this point the abdomen was marked with midline lines as well as identifying the expected flap tissue. We started by dissecting the superior margin of the flap just superior to the umbilicus down to the level of the fascia and then dissected out the inferior margin of the flap. We identified the superficial inferior epigastric artery and vein bilaterally and these were clipped off as they were too small to support the flap bilaterally. We then raised the flap from the right side first, left side second. We raised the flaps up laterally and identified several perforators in the superior portion of the right flap and subsequently similar mirroring perforators were identified on the superior portion of the left flap. The flaps were divided down the middle after the umbilicus had been dissected out. Once we were satisfied that we had identified a healthy group of perforators, we incised into the fascia of the rectus abdominis through the anterior rectus fascia and identified the deep inferior epigastric artery and veins. These were dissected down to the level of the internal iliacs and then dissected out following them until they reached the perforators, dividing all branches with hemoclips until reaching the level of the perforators that were being kept for the flap.

Once this was done, we split the muscle, divided the muscle surrounding those perforators and then again repeated similar process on the left side, freeing up the vessels all the way up to the level of the perforators, splitting the muscle and the fascia, surrounding all the perforators and sparing a medial and lateral strip of muscle bilaterally. Once we were satisfied with our flap dissection, we allowed the flaps to sit on the belly for about 20 minutes, making sure that they still appeared to be healthy. They both continued to bleed so at that point the left flap was divided and transferred up to the right chest.

At this point, using the operative surgical microscope, we cleaned up the ends of the flap vessels, the inferior epigastric vessels, and also dissected free the remainder of the vessels. We placed our clamps proximally on the internal mammaries and then ligated the vessels distally. The ends of the internal mammaries were cleaned up under the microscope. Once we were satisfied with that and we were satisfied with the inflow from the internal mammaries, we did the venous anastomosis using 9-0 nylon sutures in interrupted fashion. Then, we did our arterial anastomosis. These went smoothly and at this point, we had vigorous flow.

Now, we turned our attention to the left breast where we ligated the deep inferior epigastric vessels and brought the right abdominal tissue to the left breast. Under the microscope again, the distal internal mammaries were ligated and once we were satisfied with the internal mammary inflow, the vessels were cleaned up under the operative microscope. The venous anastomosis was performed first and then the arterial anastomosis, again using 9-0 nylon and simple interrupted sutures. When we came off of ischemic time the flap flow was excellent. At this point, we checked for hemostasis bilaterally as well as in the abdomen. The bilateral flaps were inset using 3-0 Vicryl. The right flap, because it had been only partially expanded and did not have as much need of breast skin as an envelope, had a small area approximately 4 x 2 cm in dimension that could not be closed. We applied bacitracin and Adaptic to this. Both flaps remained pink with good capillary refill throughout the remainder of the case. We found Doppler signals and placed marks at each of those sites.

We then turned our attention to the abdomen, which was elevated all the way up to the level of the xiphoid and subcostal margin. The patient was placed in lawn chair position and the three drains were placed as well as a pain pump to aid with postoperative pain control. The umbilicus site was marked on the anterior abdominal wall and the umbilicus was brought through an incision made through the abdominal flap.

At this point, the abdomen was closed in three layers using 2-0 Vicryl for the Scarpa's layer, 3-0 Vicryl deep dermal sutures, and then a running stitch using 4-0 Monocryl. The drains were all sutured in with 4-0 nylon. We sutured the umbilicus into position using 5-0 nylon. These were half-buried mattress sutures. The abdominal incision was dressed with benzoin and Steri-Strips. The umbilicus was dressed with bacitracin and Adaptic, and the breasts were dressed with bacitracin and Adaptic. The patient was kept in a flexed position. A postsurgical bra with fluffs was applied loosely, and the area was cut out to prevent pressure. Again, Doppler signals were checked and were present. The patient tolerated the procedure well and was transferred to the PACU in stable condition. The patient was extubated prior to transfer.

Code this scenario with ICD-10-CM diagnosis and ICD-10-PCS procedure codes.


ICD-10-CM Codes
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
Z40.01 Encounter for prophylactic removal of breast

Rationale: Guideline I.C.21.c.14 indicates that when “a patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in addition to a code from subcategory Z40.0, Encounter for prophylactic surgery for risk factors related to malignant neoplasms.” In this scenario the patient is being admitted for surgery directed at the malignancy and therefore the malignancy code should be sequenced before the prophylactic organ removal code based on guideline I.C.2.a.

ICD 10 PCS Codes
0HRV076 Replacement bilateral breasts with autologous transverse rectus abdominis myocutaneous flap, open approach
0KBK0ZZ Excision of right abdomen muscle, open approach
0KBL0ZZ Excision of left abdomen muscle, open approach

Rationale: 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. For this scenario the breasts are removed and replaced with abdominal muscle. The removal of the breasts (bilateral mastectomy) is a component of the replacement procedure. A separate resection code should not be applied.

The definition of Resection is cutting out or off, without replacement, all of a body part. Because the breasts are resected AND being replaced with autologous tissue in the same operative episode, this procedure goes beyond what is defined in the root operation of Resection.

The multiple procedures guideline B3.2.c would also not apply in this scenario as there are not two distinct objectives being performed on the breasts, but one distinct objective that encompasses both the removal of the breast and the reconstruction of the breast in one root operation.

Guideline B3.9 states, “if an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.” In order to reconstruct the breast, a myocutaneous (muscle and skin) flap graft from the abdomen had to be excised and moved to the breast site.

According to the overlapping body layers guideline, B3.5, the body part used for excisional procedures should correspond to the deepest layer excised, which in this scenario is the muscle.

Only one code is needed for the replacement of both the right and left breast, based on the bilateral body part guideline B4.3. If the identical procedure is performed on both sides of a body part and a bilateral body part value exists, only a single procedure code is used. However, two codes are needed for the excision of the right and left abdominal muscle because no bilateral body part value is offered in that table.

Note: If the TRAM flap remained attached to its vascular supply instead of detached and reanastomosed, it would be considered a pedicled TRAM flap instead of a free TRAM flap. The root operation for the pedicled TRAM would be “transfer” instead of “replacement.”

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