Wiki breast abscess help!!!


Millersburg, PA
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Need helping coding this one! Patient had breast reduction in 2004. We are seeing her now in home health. The doctor is stating that "apparently fat necrosis in the right breast following reduction mammoplasty becoming abscess". Would you still take it to the post operative abscess code or just the breast abscess? Also, when coding the complication, due you still listed the breast abscess?

I would absolutely query on that one if you have the option to. I code for home health, and I wouldn't at all feel comfortable coding a post-operative complication for a procedure that happened 14 years ago... perhaps if she has had reoccurring problems since the surgery it would support a post-op infection?? Either way, the MD has the final say. If they are calling it a complication to the surgery, then that is what it is, but I'd still query.

If his final answer is complication of the procedure, then just the T81.4XXA will cover it, you will not need to code the abscess also.
Fat necrosis in the breast is relatively common after breast surgery, like a mammoplasty. Sometimes the body can go in and just take care of it with no problems, sometimes the area will get surgically removed. Inevitably, there's a likely chance that scar tissue will develop there and will feel and/or appear like an abscess. It's basically one in the same; a lump of tissue. Certainly fat necrosis isn't an ideal outcome of a mammoplasty, but more often than not, it goes unnoticed and without symptoms because your body will remove that damaged tissue. I'm on the fence whether to define it a complication in this case because it's been so long since the surgery happened. I would see things differently had the patient needed surgery to remove it or if it had spread further than just a limited area. Regardless, it wouldn't be unusual for this length of time to pass before someone picked up on it. Usually they're found during mammograms or can occasionally be felt throw the skin on examination.

Needless to say, it would be a stretch to say this abscess (likely a ball of scar tissue) is a complication. The fat necrosis would have been the complication, but not the resulting abscess. In order to meet the requirements of classifying it as a "complication" there would have to be a clear statement of direct cause-and-effect in the documentation, which there is not. To make matters more difficult, these abscesses can come about from any number of ways... trauma to the breast, seatbelt injury even.

IMO, if there's going to be any connection of events, the fat necrosis would be the complication, if you could call it that, and I'd probably look at the abscess from a sequela standpoint, as you might do with scar tissue.

Nonetheless, I'd also query the provider about it.