Resolved Necrosis after breast reduction

[PhyllisN_76619]

Patient has necrosis after a breast reduction. Patient is getting a breast reconstruction due to the necrosis. Should this be coded with a complication code or just the necrosis of the skin? This is not a cosmetics case (so I can give it a cosmetic code) Patient had a mastectomy on left breast and they did a reduction on the right breast, so now the patient has necrosis due the breast reduction. complication code or just necrosis of skin ? I am just necrosis, since this is something that can happen

 

[Lori]

Breast fat necrosis is nonviable adipose cells from injured or ischemic breast tissue that is replaced with scar tissue and presents as a palpable nodule. Breast fat necrosis has various etiologies and implications; therefore, a careful patient history is imperative to properly evaluate the patient. The most common etiology of fat necrosis is recent breast surgery

Documentation of Complications of Care Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

Complications of surgery and other medical care When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

Read more on this thread:

https://www.cco.community/threads/complication-of-care.6739/#post-16005

So unless a complication is noted in the documentation:

N64.1
Fat necrosis of breast

 

[PhyllisN_76619]

Thank you for your help. I appreciate you.