In this month’s Registry Partners CTR Coding Break, we discuss coding surgical procedures for 2023 breast cases. For cases diagnosed 1/1/2023, the Surgical Procedure of Primary Site at this facility field is no longer applicable and has been replaced by a new data item titled Rx Hosp-Surg 2023. This new data field has been added for all sites and today we will be discussing how to code surgical procedures for breast cancer to this new field. The good news is the codes are similar to the ones we’re accustomed to using with the addition of the letter A to the beginning and the number zero to the end. The definitions for each surgical procedure have not changed. For example, for cases diagnosed between 2003 and 2022, a partial mastectomy was coded to 20 and now for cases diagnosed in 2023, we’re instructed to code a partial mastectomy to A200. Similarly, a simple mastectomy was previously coded to 40 and with cases diagnosed in 2023, a simple mastectomy will be coded to A400.
In addition to the new surgery data field, STORE 2023 instructs to continue collecting the 4 surgery and reconstruction data items that were added in 2022: Rx Hosp-Surg Breast, Rx Summ-Surg Breast, Rx Hosp-Recon Breast, and Rx Summ-Recon Breast. Rx Hosp-Surg Breast records the most definitive surgery performed at the reporting facility and the Rx Summ-Surg Breast is a summary code that records the most definitive surgery performed at any facility. In a similar fashion, Rx Hosp-Recon Breast and Rx Summ-Recon Breast capture the immediate reconstruction performed at the reporting facility and at any facility, respectively. It is important to note only immediate reconstruction performed under the same anesthesia as the breast resection is collected. We do not collect delayed reconstruction in this field. In addition, STORE 2023 instructs to only include reconstruction performed to the ipsilateral breast in this data item. Be sure not to confuse the reconstruction codes with the new 2023 surgery codes as they both begin with the letter A. The presentation concludes with three case scenarios.
Thanks again to all who joined us live this month! If you weren’t able to join us or would like to download this presentation as a PDF click here.