Parenchymal remodelling of breast tissue

Created Aug 2012
Reviewed Dec 2019

Query

We have ‘parenchymal remodelling of breast tissue’ documented recently, which is also documented as ‘glanduloplasty’.  Initially we thought it was just the way they close up but the clinician says there is more time involved.  The only code we can come up with is 90720-00 [1759] Other procedures on breast and it changes the DRG from minor to major.

As it appears to be a new procedure does NZCA agree with the procedure code suggested?

Below are two examples.

OPERATION 1:
Right breast total duct excision plus excision of mammary duct fistulas at 10 o’clock and 2 o’clock

Procedure:  
General anaesthetic, routine prep and drape, IV Augmentin and Cefazolin.
Periareolar incision used and an elliptical sliver of skin taken with 10 o’clock fistula. Separate elliptical incision utilised to excise mid areolar 2 o’clock fistula as well. Superior and inferior flaps raised. Total duct excised. Ducts excised from subcutaneous aspect of nipple down to approximately 2cm deep into breast tissue. Tissue excised in continuity with 10 o’clock and 2 o’clock fistulas. Haemostasis achieved. Parenchymal remodelling to reconstitute previous nipple/areolar complex mound using 2/0 Vicryl. 4/0 Monocryl to close skin. Steristrips and Opsite.

OPERATION 2:
Left breast hookwire localised wide local excision with Level 2 oncoplastic remodelling, left sentinel node biopsy, left axillary node dissection, and right breast reduction

Procedure:
General anaesthetic, prophylactic antibiotics, sequential compression devices, patient prepped and draped in sterile manner.  Keyhole skin incisions marked out which included lateral extension. Surgery started on the left side with de-epithelialisation of the skin around the areola and down the central part of the inferior breast.  The wide local excision was completed by excising essentially all the upper outer quadrant of parenchyma.  Any bleeding was controlled with bipolar diathermy.  The dissection was from the subcutaneous tissues down to pectoralis fascia. The specimen was marked with three stitches and three clips at 3 o’clock, two at 6 o’clock and one at 9 o’clock position.  Additional upper lateral and lower lateral shaves were then taken.  These included all of the lateral breast tissue so that no further breast parenchyma was left laterally.  This also incorporated the axillary tail in the upper lateral shave.  An additional shave of subcutaneous tissue was taken around the hookwire entry site through the skin. An inferior medial shave was taken. Two shaves were taken deep to the nipple; these were labelled (1) which was deep and (2) which was superficial.  Once these shaves were taken the oncoplastic remodelling continued with excision of the lateral tissue inferiorly.  An inferior medial pedicle was raised and rotated as much as possible up into the area of parenchyma loss; this was secured in position with 2/0 Vicryl.  A 15 French Blake drain was placed.

Response

Following the submission of this query NZCA members were asked to consult with their breast surgeons in order to obtain further information about ‘parenchymal breast remodelling’. 

The breast surgeons consulted agreed that “parenchymal breast remodelling has become standard component of most, more extensive breast excisions (typically cancer surgery and a few extensive excision biopsies – e.g. for radial scar) and has extended surgical time, increased post-op pain, can result in an overnight stay that might not have been required and the use of a drain.  In addition there is a higher risk of post-op haemorrhage and possible return to theatre.”

The breast surgeons also stated that there are varying complexity levels of parenchymal breast remodelling.  Therefore, in order for clinical coders to clearly identify the levels of complexity and determine if an additional procedure code should be assigned or not, the levels of complexity have been defined below.

These definitions are based on information provided as part of a clinical response to an NZCA request for information on parenchymal breast remodelling.

Onco-plastic level 1
Generally the procedure performed would be a wide local excision with moderate tissue mobilisation or direct wound closure.  An additional procedure code is not required where the documentation indicates onco-plastic level 1.

Onco-plastic level 2
Procedures performed for this level are defined by significant breast remodelling, typical examples include:

  • Wide local excision in the form of quadrantectomy
  • Central breast excision with Grisotti flap remodelling

An additional procedure code should be assigned when onco-plastic level 2 is documented.  Clinical coders would need to refer to the operation note to determine the appropriate procedure code to assign.  The procedure for onco-plastic level 2 could include reduction mammoplasty, local flap, or a more specific flap e.g. Grisotti or pedicle flap (reconstruction).

Note: The procedure code for onco-plastic level 2 would be assigned in addition to the appropriate excision/resection procedure code(s).

Onco-plastic level 3
Procedures performed for this level maintain breast shape and symmetry with reconstruction techniques rather than glandular flaps.  Example:

  • Wide local excision - partial mastectomy lateral breast with latissimus dorsi min-flap reconstruction         

Clinical coders should refer to the operation note to confirm procedure code assignment for onco-plastic level 3.  Generally this will involve a flap reconstruction, therefore, refer to the ACHI Index.

Reconstruction
- breast
- - with 
- - - flap 45530-02 [1756]

Note: The procedure code for onco-plastic level 3 would be assigned in addition to the appropriate excision/resection procedure code(s).

It is recommended that clinical coders consult with their breast surgeons and ask if they could document in the operation note the appropriate levels.

Response to the above queries

Operation 1
In this operation the parenchyma remodelling would be considered onco-plastic level 1, as it is nothing more than tissue mobilisation with direct wound closure.  Therefore, an additional procedure code is not required to be assigned.

Operation 2
In the operation code title there is documentation of “Level 2 onco-plastic remodelling”.  When referring to the detailed procedure information, the documentation states:

“Once these shaves were taken the onco-plastic remodelling continued with excision of the lateral tissue inferiorly.  An inferior medial pedicle was raised and rotated as much as possible up into the area of parenchyma loss; this was secured in position with 2/0 Vicryl.  A 15 French Blake drain was placed.” 

The procedure code assigned for this onco-plastic level 2 procedure is 455300-02 [1756] Reconstruction of breast using flap following the ACHI index:

Flap
- for
- - reconstruction of breast 45530-02 [1756]

Free text should be used to specify onco-plastic level 2.

Clinical reference:
Mr Michael Landmann MD (Heidelberg, Germany) 1985, German Surgical Board Certification 1994, FRACS 1998, PDiplHealInf (Otago Distinction) 2001.

Back to top