Case #693

Procedures to treat lymphedema.

Added by Ralph Dahlgren 7 months ago. Updated 5 months ago.

Status:AcceptedStart date:2020-02-28
Priority:MinorSpent time:-
Target version:Target version 2021
Initiator:Sweden Target year:2021
Case type:Minor Owner / responsible:National organisations
MDC:GEN Old forum status:
Target Grouper:SWE


2020-02-28 R Dahlgren
The health care providers have contacted the Swedish DRG-team concerning a special group of in-patients.
This is the in-patients with lymphedema leakage that make the fat tissue increase tremendously.
The science says that especially for more extended stages of lymphedema with irreversible changes non-operative treatment will give inappropriate reduction of volume and complaints.
Severe lymphedema patients have a lymphatic disease that can occur after cancer treatment when lymph nodes are removed to prevent the spread of cancer. Radiation treatment is also often given as treatment afterwards. The lymph vessels pass through the lymph nodes and when the lymph nodes are removed, the lymph flows into the fat between the skin and the muscles. The lymph causes chronic inflammation and this stimulates the formation of adipose tissue. There are also congenital lymphedema due to heredity or spontaneous mutations. These affect especially the young girl in the final growth spurred (?high speed) in her teens when the defective lymphatic system is unable to drain the lymph.
The vast majority of lymphedema patients have no additional diagnosis except the ones mentioned above. They are that we in Sweden call ‘ASA 1’. This means that the patients are low risk when having surgery.
These patients are now grouped to different DRGs. In these DRGs they don’t fit resource wise.

The surgery done of these extreme lymphedema patients use a lot of recourses. Time for surgery, 3-6 hours. The duration of stay 5-8 days.
The resources used do that the patients does not belong to the DRGs they are grouped today.
The involved ICD-10 codes are:
I890 Lymfödem som ej klassificeras på annan plats (Lymphoedema, not elsewhere classified)
I890A Lymfangiektasi
I890B Lymphoedema praecox
I890C Lymfödematös keratoderma
I890W Annat lymfödem som ej klassificeras på annan plats
I972 Lymfödem efter mastektomi (Postmastectomy lymphoedema syndrome)
The procedures are:
PJW30 Anläggande av lymfovenös anastomos (PJSW30 Lymphovenous shunt)
PJW99 Annan operation på lymfsystem (PJSW99 Other operation on lymphatic system)
QCJ00 Fettsugning, övre extremitet (QCSJ00 Liposuction in upper limb)
QDJ00 Fettsugning, nedre extremitet (QDSJ00 Liposuction in lower limb)
These in combination are used on the patients described above.
Department of Health and Welfare Sweden – 2020-02-28
The ICD-10 codes I972 and I890 with combination with procedure codes PWJ30/99, QCJ/QDJ00 uses resources that have a mean costs around 112 685 Swe kr (~11 000 Euro) and for inpatients a length of stay 5-8 days.
They are now grouped to different DRGs;
J20E/C Plastikkirurgiska operationer i hud och underhud (DRG 268 Skin & subcutaneus tissue plastic procedures/Skin & subcutaneus tissue plastic procedures w cc)
J60E/C Lättare hudsjukdomar, hudtumörer inkl skivepitelcancer (DRG 284 Minor skin disorders w mcc/Minor skin disorders w cc)
K30N Benigna bröstsjukdomar (DRG 276 Non-malignant breast disorders)
Z60N Annan sällsynt, eller felaktig, kombination av huvuddiagnos och åtgärd (DRG 477N Rare or incorrect combination of diagnosis and other procedure)
Resource wise these in-patients does not fit there.
Department of Health and Welfare Sweden – 2020-02-28
Sweden wants to add a new grouping property to the ICD-10 codes and procedure codes above.
The new grouping properties are combined in new two rows in DRGlogic that will lead to DRG J01E/C Hudtranspl & revision för hudulcus el cellulit, komplicerat that in Sweden has about the same resource use as above.
J01C Rev/hudtrpl sår/cellulit K mean cost SWE kr 169 370 (~17 000 Euro)
J01E Rev/hudtrpl sår/cellulit U mean cost SWE kr 103 055 (~10 000 Euro)
(263/264 Skin graft &/or debrid for skin ulcer or cellulitis w/o cc/ Skin graft &/or debrid for skin ulcer or cellulitis w cc)

Decided changes
Department of Health and Welfare Sweden – 2020-02-28
Sweden wants this these changes to be implemented in SWE PL version 2021.
DRG change
These patients will be grouped from different DRGs mentioned above to DRG J01E/C.
Technical change
The ICD-10 codes mentioned above will get the new pdgprop ‘09P70 Lymphedema or lipohypertrophy’.
The procedure codes will get a new ‘PROCPR 40V65 Correction of lymphedema or lipohypertrophy’
See the Excel-file called ‘Decision C764 Procedures to treat lymphedema’.

Decision C764 Procedures to treat lymphedema.xlsx (27.9 KB) Ralph Dahlgren, 2020-02-28 22:42

Decision C764 Procedures to treat lymphedema_#693.xlsx (29.3 KB) Kristiina Kahur, 2020-03-26 18:09


#1 Updated by Martti Virtanen 7 months ago

2020-03-03 Martti Virtanen
The proposal is clinically reasonable and seem to improve resource omogenity of the groups.

I have two questions:

1) Since the the property 40V65 is not used for any other situation the correction of lipohypertrophy when the cause is lymphoedema, I think the name should be only 'Correction of lymphedema'

2) There is one additional code in ICD-10 for lymphoedema Q8200 'Hereditary lymphoedema'. In ICD-11 this code is combined to 'Primary lymphoedema' that in ICD-10 clearly belongs to the group I8900 'Lymphoedema, not elsewhere classified'. It should probably also have the principal dx property 09P70.

#2 Updated by Ralph Dahlgren 7 months ago

2020-03-08 Ralph Dahlgren
Martti are correct, the code Q8200 'Hereditary lymphoedema' should also be incuded as mentioned above. I did not remember to include that ICD-10 code. The surgery is also done on that indication naturally.
Thank you Martti for making it more correct.

#3 Updated by Martti Virtanen 7 months ago

  • Description updated (diff)

#4 Updated by Kristiina Kahur 6 months ago

Nordic Casemix Center/Kristiina Kahur 26-3-2020

Expert group 2020-03-09: The change was accepted for Sweden. The TC are corrected according to Martti's comment and attached.

#5 Updated by Ralph Dahlgren 5 months ago

2020-04-16 Ralph D
This comment is alittle late but still valid.
This concerns Marttis coment 2020-03-03 the first Point made.
In this case there is a new proc prop 40V65 introduced. Martti suggested that the text should be 'Correction of lymphedema'. Sweden want the text to be 'Correction of lymphedema or lipohypertrophy'. This due to the fact that the different procedures that gets the new procp prop are totally different approach to the patient problem, lipohypertrophy. We think that this difference should be shown in the text.

#6 Updated by Kristiina Kahur 5 months ago

Nordic Casemix Center/Kristiina Kahur 22-4-2020

The text of 40V65 was corrected. Case is closed.

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