Case #683

Breast lift/ mastopexy

Added by Kristin Dahlen 5 months ago. Updated 2 months ago.

Status:AcceptedStart date:2020-02-13
Priority:MinorSpent time:1.20 hour
Assignee:Kristin Dahlen
Target version:Target version 2021
Initiator:Norway Target year:2021
Case type:Minor Owner / responsible:National organisations
MDC:MDC09 Old forum status:
Target Grouper:EST, FIN, ICE, LAT, NOR, SWE


A breast lift surgery or mastopexy is performed to obtain a higher position and a fuller curve of breasts that have lost their elasticity and firmness. There are many causes for these kinds of breast changes, including pregnancy, breastfeeding, weight fluctuations, aging, gravity and heredity.

The procedure HASD40 'Mastopexy' has procedure properties 30S04 Partial mastectomy or other breast procedure and 14S90 Significant operation for obstetrical patient (Norwegian version). Dependent on the indication in MDC 30 the DRG will be one of the following:

260O Subtotal mastektomi ved ondartet svulst, dagkirurgisk behandling
261O Mammaoperasjon ved godartede sykdommer ekskl biopsi/lokal eksisjon, dagkirurgisk behandling
259 Annen mammaoperasjon ved ondartet svulst m/bk
260 Annen mammaoperasjon ved ondartet svulst u/bk
261 Mammaoperasjon ved godartede sykdommer ekskl biopsi/ lokal eksisjon

However, the indication for this procedure might as well be from MDC 09 diseases and disorders of the skin.
One of the correct indications/codes might be L987 'Loose excessive skin'. Using this diagnosis code together with HASD40 the DRG result will be 477/ 477O. As this indication is not rare, we would like another grouping result than 477/477O.

Per 2 tertiary 2019 it is 187 cases with HAD40 (HASD40) mastopeksi in the Norwegian data. These cases are grouped to different DRG's based on the main condition and other procedure codes. Most of the cases (36%) do have Z421 'Follow-up care involving plastic surgery of breast', 10% of the cases do have L987 'Loose excessive skin'. However, only some of those cases (approx. 3%) group to DRG 477/477O.

In the Norwegian version we have at least three different opportunities for a new grouping of the cases now grouped to DRG 477/477O. Both DRG 268/ 268O Plastiske operasjoner på hud og underhud and DRG 531/531O Annen plastikkirurgi etter stor vekttap in MDC 9. DRG 261/261O might also be DRGs to consider.

As the diagnosis code belongs to MDC 9 we might prefer DRG 268/268O.

Procedurecode HASD40 'Mastopexy' shall be given property 09S02 Plastic procedure and be grouped to DRG 268/268O if the main diagnosis is from MDC 9, for example L98.7 Mye og overflødig hud og underhudsvev.

Technical change
PROC PROP 09S02 will be given to procedure code HASD40 'Mastopexy'.

Ncsp_plus 2020 HASD and HASE.xlsx (476 KB) Martti Virtanen, 2020-03-31 15:23

TC_683_from_NDMS.xlsx (12.9 KB) Kristiina Kahur, 2020-04-13 16:55

TC_683_from_NDMS_2.xlsx (11.9 KB) Kristiina Kahur, 2020-04-30 10:59


#1 Updated by Kristiina Kahur 5 months ago

Finnish National DRG-Centre/Kristiina Kahur 24-2-2020

109 cases with HAD40 (HASD40 ncsp+ code) in 2018 Finnish data (5 university hospitals). No cases with the combination HAD40+L987.
The change makes clinically sense.
Finnish cost data cannot provide the support to this change.

#2 Updated by Martti Virtanen 4 months ago

  • Description updated (diff)

#3 Updated by Martti Virtanen 4 months ago

2020-03-03 Martti Virtanen
The proposed change is clinically reasonable.

#4 Updated by Ralph Dahlgren 4 months ago

2020-03-08 Ralph Dahlgren
First I have a question, I do not understand, probably due to my poor English, and that is the sentences ‘Per 2 tertiary 2019 it is 187 cases with HAD40 (HASD40) mastopeksi in the Norwegian data. ….., 10% of the cases do have L987 'Loose excessive skin'. However, only some of those cases (approx. 3%) group to DRG 477/477O.
My question is: How come some cases with the main diagnose L987 are grouped to DRG 477/477O and others are not?

In Swedish in care we have no cases in the Z60N (477) with procedur code HAD40.
In Swedish out care we have 2 cases in Z60O (477O) with procedur HAD40. After the adding of procpro 09S02 Plastic Procedure to HAD40 they are grouped to DRG J20O.
Prospective weights, weight 1 is SEK 61 233 kr.:
DRG DRG Text Weight 2020 Cost-Outlier limit
J20O Plastic skin / subcutaneous skin O 0.270 (SEK 16 533 kr.) 69 882
Z60O Other rare or fault comb O 0.068 (SEK 4 164 kr.) 99 999 999
These two cases have an average cost of SEK 25 215 kr. They fit better in J20O looking at use of recource.

When looking at the procedure code HAD40 I found other ‘Breast procedures’. I do not say I have found them all due to lack in time for this investigation.
These procedures have almost the same grouping properties as HAD40 and should be grouped about the same way.
They are:
HAD00 Breast enlargement
HAD10 Enlargement of breast with prosthesis
HAD20 Liposuction in breast
HAD30 Breast reduction with transposition of areola
HAD35 Breast reduction with areola transplantation
HAD40 Mastopexi
HAD45 Correction of inverted mamill
HAD50 Removal of inoperable breast prosthesis
HAD55 Capsule cleavage in breast
HAD57 Extirpation of fibrous capsule around breast implant
HAD60 Replacement of breast prosthesis
HAD99 Other corrective surgery on the breast (i)
HAE00 Reconstruction of breast with prosthesis
HAE05 Reconstruction of the breast with the abdomen and prosthesis
HAE10 Reconstruction of breast or graft breast
HAE20 Reconstruction of areola and mammary graft or lamb
HAE99 Other breast reconstruction (i)

Why are they not involved in this case? There might be more codes that I haven’t found, se above.
Sweden has in our Cost data 2018 (only controlled one year) the following procedures in Z60O (477/477O) with these procedures.

DRG Procedure Number Mean Cost
Z60O HAD10 Breast Enlargement with Prosthesis 2 31 739 SWE kr.
Z60O HAD30 Breast Reduction with Areola Transposition 5 32 481 SWE kr.
Z60O HAD40 Mastopexi 2 25 215 SWE kr.
Z60O HAD50 Removal of inoperable breast prosthesis 3 19 653 SWE kr.
Z60O HAD60 Replacement of breast prosthesis 1 25 397 SWE kr.
60O HAD99 Other Breast Correction (i) 5 14 002 SWE kr.

How is it in other countries?
The procedures mentioned above that we have data on also fit better in other DRGs than Z60O (477O) looking at Swedish data
Due to lack in time no control how these will be grouped if also get 09S02 has been done.
We also have in our cost data 2018 three cases with different procedures above that are grouped to Z60N (477) and they are not controlled either.

I think that this case should be further investigated with more codes included as well as with control of other countries cost data on these codes that I mention above but maybe also other codes.

So Sweden does not agree to just correct one of many codes.
All of them should be done at the same time. The countries should group the data before and after adding 09S02.
Norway has a grouper, Sweden also and everyone has recently gotten NDMS.
So now we all can help each other with grouping the suggested changes after decided which procedure codes should be involved.

#5 Updated by Kristiina Kahur 4 months ago

  • Status changed from Active to Further active

Nordic Casemix Center/Kristiina Kahur 26-3-2020

Based on the discussions during the expertgroup meeting it was decided that the changes concerns only procedure code HASD40 'Mastopexy' which will be given PROCPR 09S02 in all versions.

However, the case needs further analysis and another discussion next year.
The case remains further active.

#6 Updated by Kristin Dahlen 3 months ago

We have made further analyses and decided that we will include all of the procedure codes mentioned by Ralph. This will mean that the following procedures shall have PROCPR 09S02. The cases with one of the following procedurecodes and with main diagnosis from MDC 9 will Group to DRG 268/268O.

HAD00 Augmentasjonsmammoplastikk
HAD10 Augmentasjon av mamma med protese
HAD20 Fettsuging i mamma
HAD30 Reduksjonsmammoplastikk med transposisjon av areola
HAD35 Reduksjonsmammoplastikk med transplantasjon av areola
HAD40 Mastopeksi
HAD45 Eversjon av brystvorte
HAD50 Fjerning av mammaprotese
HAD55 Incisjon av fibrøs kapsel rundt mammaprotese
HAD57 Eksisjon av fibrøs kapsel rundt mammaprotese
HAD60 Utskifting av mammaprotese
HAD99 Annen plastisk operasjon på mamma
HAE00 Rekonstruksjon av mamma med protese
HAE05 Rekonstruksjon av mamma med bløtvev og protese
HAE10 Rekonstruksjon av mamma med transplantat eller lapp
HAE20 Rekonstruksjon av areola og brystvorte med transplantat eller lapp
HAE99 Annen rekonstruksjon av mamma

#7 Updated by Martti Virtanen 3 months ago

2020-03-11 Expert group
This note is written delayed, therefore the position is wrong.

Expert group accepted the original proposal for all countries but decided to leave the case open for the discussion of the additional proposal from Sweden.

#8 Updated by Martti Virtanen 3 months ago

2020-03-31 Martti Virtanen

Since the Swedish proposal is now accpeted by Norway, it seems that it would be logical that the proposal of Sweden should be applied for all countries.
This means that all NCSP+ codes starting with HASD and HAED and all national codes linked to these would get the property 09S02.
The attached file lists all these codes and all linked national codes.

The countries should before 7th April respond wether they accept the proposal or not?

#9 Updated by Elina Hermiö 3 months ago

We had a look at our data and agree to add PROCPR 09S02 to HASD and HASE codes listed in Kristin’s update.

This changes is clinically meaningful, and would affect very few cases in Finnish version. There are four cases with HASD and HASE procedure codes with main diagnosis from MDC9 in our data in DRG 477 or 477O currently which would regroup to more propriate DRG 268 or 268O. We would like to have it implemented into Finnish 2021 version.

#10 Updated by Birna Björg Másdóttir 3 months ago

Iceland accepts the Swedish proposal and wants it applied for the Icelandic groupper.

#11 Updated by Malle Avarsoo 3 months ago

Estonia accepts this clinically significant change.

#12 Updated by Kristīne Putniņa 3 months ago

Malle Avarsoo wrote:

Estonia accepts this clinically significant change.

#13 Updated by Kristīne Putniņa 3 months ago

Looks I chose the wrong button : )
Latvia also accepts those changes and asks to introduce in a grouper.

#14 Updated by Kristiina Kahur 3 months ago

  • File TC_683_from_NDMS.xlsx added
  • Status changed from Further active to Accepted
  • Target Grouper EST, FIN, ICE, LAT, NOR, SWE added

Nordic Casemix Centre/Kristiina Kahur, 13-4-2020

Based on the feedback after the expertgroup meeting, the changes were accepted in all national versions, i.e. all NCSP+ codes starting with HASD and HAED and all national codes linked to these get the property 09S02.
The updated TC are attached to the ticket.
Case is accepted.

#15 Updated by Ralph Dahlgren 3 months ago

2020-04-15 Ralph D
I want to remind that Sweden also wanted to do en recource investigation before accepting all the codes to the Swedish definitiontables that I said might fit in with HAD40 (HASD40) mastopeksi, se my comment above. Due to Covid-19 this has not been done yet. We will as soon as possible come back with an answer if we also want it to be implemented.

#16 Updated by Ralph Dahlgren 3 months ago

2020-04-22 Ralph D
Sweden have done a resource investigation, a qiuck one that is. We agree that these other codes mentioned above should also get 09S02.
We also want this implemented in the Swedish definitiontables for PL2021.

#17 Updated by Kristiina Kahur 3 months ago

Nordic Casemix Centre/Kristiina Kahur, 22-4-2020

Thank you for confirmation. This change is implemented in NDMS in all countries' 2021 tables according to TC.

#18 Updated by Ralph Dahlgren 2 months ago

2020-04-29 Ralph Dahlgren
Going throuogh the technical Changes for this case I do want to make a question about the last code in the NCC technical Changes.
The code that I make make this question about is QBJ30 (NCSP QBSJ30). This code has nothing to do with Breast surgery. Sweden do not want this code to be included in our technical Changes for this case. The code involves surgery on stomach and is something different and should not be included in this case in our opinion.
Sorry for the late remark but SWE are late this year.

#19 Updated by Kristiina Kahur 2 months ago

Nordic Casemix Centre/Kristiina Kahur, 30-4-2020

Thank you Ralph for your comment. The row with Code QBJ30 (NCSP+ QBSJ30) was redundant and irrelevant for this TC. Updated TC are attached.

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