Fat Graft Coding (During another procedure)

[Brian]

Hello,

I was wondering if anyone else has come across this scenario....


We have patients who undergo pituitary adenoma removal through transnasal/transphenoidal approach - followed by fat grafting. The surgeon harvests abdominal fat and then puts it into the sphenoid sinus after the tumor has been removed to complete what he calls "sinus obliteration". He clearly calls this a fat graft in his operative note.

Would you could the fat graft in addition to the removal of the pituitary adenoma? Is this considered a normal part of the procedure? Coding the "graft" changes the DRG and really skews what this patient population should be.

Instead of DRG 614 - Adrenal and Pituitary Procedures, the fat graft throws us into DRG 620 - OR procedures for obesity.

Thoughts?

[DrGold]

As you probably know from this issue, there is a Coding Clinic citation that reads:

Fat excision for grafting to fill an acquired defect
Coding Clinic, Third Quarter 1992 Page: 13
Effective with discharges: July 1. 1992
Question:

How do you code excision of fat from the abdomen for grafting to the sphenoid sinus following the partial transsphenoidal removal of a hemorrhagic pituitary tumor?

Answer:

Assign code 07.62, Partial excision of pituitary gland, transsphenoidal approach, for the procedure performed.

In accordance with Coding Clinic, Second Quarter, 1998, p. 20, it is appropriate to assign code
86.89, Other repair and reconstruction of skin and subcutaneous tissue, for a fat graft.

But this has been superseded and the remedial answer is:

"An additional code would not be assigned for any excision of fat, muscle, or cartilage used to fill a void."

In other words, the advice is NOT to assign the code. And, if you don't, it's back to where it should be.

Then, unfortunately, someone asked the question again and we got:

Clarification - fat graft Coding Clinic, First Quarter 2000 Page: 26
Effective with discharges: April 1, 2000
Clarification, Fat Graft

Question:

When fat is harvested and used to fill a void during surgery, is it appropriate to assign code 86.89, Other repair and reconstruction of skin and subcutaneous tissue?

Answer:

It is appropriate to assign code 86.89, Other repair and reconstruction of skin and subcutaneous tissue, for a fat graft. This is consistent with advice previously published in Coding Clinic, Second Quarter 1998, p. 20, which supersedes advice published in Coding Clinic, Third Quarter 1992, p. 13.

In other words, they superseded their superseding by going back to where they were in the first place. I would NOT assign the code for filling the void with fat at all. This has to go to Coding Clinic and CMS.

Dr. G.

[badger]

My codebook references a more recent Coding Clinic from 2002, 4th, 107. I do not have access to Coding Clinic, but surely someone here does!
What is the update?

[DrGold]

It refers to closing a dural hole in anterior and posterior fusion procedures with some fat and emphasizes that 86.89 is to be used there for the fat graft. I wonder if THAT groups to Operations for Obesity . I have this question in front of CMS and AHA Coding Clinic for discussion. Why a minimal procedure should drive the DRG to Surgery for Obesity is just plain ludicrous.

Dr. G.

[Allen]

As of 2010, the code would not be 86.89, it would be 86.87. No code would be assigned for the excision/harvesting of the fatty tissue, only the grafting to the recipient site for the repair.

The question you have to ask yourself is: "Would a fat graft be a routine part of this procedure/is this done on most cases OR is it a more extensive repair/NOT done on most cases." Currently the way the advice is structured, you would code this graft. However it it is determined that this is routine for the procedure, a case could be made for an update to the coding advice and a corresponding slight bump in the procedures weight/reimbursement to signify that is a routine/integral part of the repair.

The preceding advice is good practice ANY time you ask yourself "is x included in y procedure". (remember to ask, "Is x NORMALLY done when Y is also done"). This of course, only when coding clinic doesn't have an entry answering the question one way or another definitively.

Fat Grafting

Coding Clinic, Fourth Quarter 2010 Page: 132
Effective with Discharges: October 1, 2010

Effective October 1, 2010, new codes have been created to describe fat graft to breast (85.55); fat graft of skin and subcutaneous tissue (86.87); and extraction of fat for graft or banking (86.90).

Fat grafting is a technique in which prepared fat cells are injected in order to correct soft tissue defects. Fat grafts are most often used in reconstructive procedures (e.g., following lumpectomy and as an adjunctive procedure with post-mastectomy reconstruction). Fat grafts are also used in cosmetic procedures, such as lip augmentation and facial wrinkle reduction.

Autologous fat is used for grafting and is procured via liposuction. The fat is usually harvested from an unobtrusive area such as the abdomen, flank or thigh. After the surgeon injects a tumescent fluid, a liposuction cannula is placed subcutaneously and the adipose tissue is aspirated. The lipoaspirate is processed in order to concentrate the number of fat cells. This is normally done as a back table procedure during the same operative episode. The fat is filtered by centrifuge to remove the excess fluid. This allows for a more concentrated graft, consisting of adipocytes with a small volume of adipose progenitor cells.

More recently, new techniques have been developed that enrich the fat graft with adipose-derived stem and regenerative cells. The regenerative cells promote neoangiogenesis and prevent cell death. This enrichment process divides the lipoaspirate into two aliquots. One aliquot is biochemically digested to render the adipose stem cells and other regenerative precursor cells. These are then mixed with the remaining portion of lipoaspirate, which creates a progenitor-enriched fat graft with a greater concentration of stem and regenerative cells.

The technique for placement of the fat graft into the recipient area involves placing a cannula into the site of the defect and injecting the fat. The needle is passed through several layers and different directions (fanning) to ensure even distribution and maximal surface area of the fat graft. This maximizes exposure of the fat graft to the surrounding native tissue to increase availability of oxygen and nutrients until the graft establishes a new blood supply. In breast reconstruction, the fat graft is placed into the layers surrounding the mammary glands to gain the correct contour and texture similar to the native breast.

Fat grafting of the breast can be performed as a solo procedure or in the same operative episode as other reconstructive procedures (e.g., myocutaneous flap, revision mammoplasty, etc.).

New code 85.55 Fat graft to breast

Includes: extraction of fat for autologous graft
Autologous fat transplantation or transfer
Fat graft to breast NOS
Fat graft to breast with or without use of enriched graft
Micro-fat grafting

Excludes: that with reconstruction of breast (85.70–85.79)

New code 86.87 Fat graft of skin and subcutaneous tissue

Includes: extraction of fat for autologous graft
Autologous fat transplantation or transfer
Fat graft NOS
Fat graft of skin and subcutaneous tissue with or without use of enriched graft
Micro-fat grafting

Excludes: fat graft to breast (85.55)

New code 86.90 Extraction of fat for graft or banking
Harvest of fat for extraction of cells for future use
Liposuction to harvest fat graft

Excludes: that with graft at same operative episode (85.55, 86.87)