Amazing tips for Cpt code for Sentinal lymph node biopsy

Sentinal lymph node biopsy
(Photo credit: Wikipedia)

Sentinal lymph node biopsy and lymphadenectomy


Sentinal lymph node biopsy is not the same as lymphadenectomy, and confusing the two could have direct effects on the accuracy of your claims.

Follow these four tips to be sure you're getting everything your practice deserves from its lymph excision procedures.

Tip 1: If Biopsy Results Lead to Subsequent Excisions, Biopsy Is Billable

When the surgeon performs a sentinal lymph node biopsy prior to an unplanned 

partial mastectomy (either with or without lymphadenectomy) -- and the subsequent excisions are a result of biopsy findings -- you may report the sentinal node biopsy separately.

CPC Practice Exam - Medical Coding Study Guide Please Click Here!

CMS goes on record: "Sentinal lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy without lymphadenectomy," according to guidelines set forth in Chapter 3 of the National Correct Coding Initiative Policy Manual for Medicare Services.

In simple language: You can report both sentinal lymph node biopsy and lymphadenectomy during the same session as long as:

1.     The lymphadenectomy is unplanned at the time of the biopsy

2.     The decision to perform lymphadenectomy (at the same or a later session) is based on the results of the biopsy.

Example: The surgeon takes a biopsy of the sentinal axillary node (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). The pathology report indicates that the malignancy has spread, so the surgeon follows up with a lymphadenectomy (for example, 38745, Axillary lymphadenectomy; complete) to remove the affected tissue.

In this case, because the biopsy led to the decision to perform the mastectomy, you may report both 38525 and 38745.

Many payers will require that you append modifier 59 (Distinct procedural service) to the appropriate biopsy code (38500-38530) to further differentiate the procedure from the follow-up lymphadenectomy. In addition, your documentation should make clear that the biopsy results provided the justification for and led to the decision to perform the subsequent excisions.

Tip 2: Don't Unbundle Sentinal lymph node Biopsy With Planned Lymphadenectomy

You should not separately report sentinal lymph node biopsy (38500-38530) and a planned lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinal node biopsy in the more extensive, same-location lymphadenectomy.

Here's what Medicare says: "Sentinal lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy]," says Triple-S's local coverage determination (LCD) (this policy is typical of other Medicare carrier guidelines).

Bottom line: If the surgeon prospectively plans to perform lymphadenectomy, you should not separately report a sentinal node biopsy. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinal nodes.

Specificity Identifies Sentinal lymph Node Biopsy

You should consider sentinal node biopsy (38500-38530) to be a more "targeted" and less invasive procedure than lymphadenectomy (38700-38780).
The sentinal node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other site). If the sentinal lymph node is negative for metastases, the surgeon need not perform a complete lymphadenectomy (which removes a much greater volume of tissue), thereby avoiding the morbidity and complications associated with that procedure.

Keep in mind, however, that the above sequence of events would be rare. The purpose of a sentinal node biopsy is to avoid a lymphadenectomy, if possible. Therefore, surgeons generally perform lymphadenectomy only if the results of the sentinal node biopsy show malignancy.

Tip 3: Excisions, Not Incisions, Count for Sentinal Node Coding
When the surgeon performs more than one sentinal lymph node biopsy, you should realize that the number of incisions -- not the number of biopsies -- determines the number of codes and/or units.

In other words: If the surgeon performs two biopsies through the same incision, you may report only a single code. If the surgeon takes three biopsies from two different incisions, you may report two codes, etc.

Important: When reporting more than one biopsy code, append modifier 59 (Distinct procedural service) to the second and subsequent codes.

Example: Using one incision, the surgeon biopsies a superficial node and a deep axillary node. In this case, because the surgeon accesses the node through a single incision, you may report only the more extensive (higher-paying) code -- in this case, 38525.

If the surgeon performs the same procedures through different incisions, you may report 38525 and 38500, attaching modifier 59 to the lesser (lower-valued) procedure -- here, 38500 -- to indicate a separate anatomic area.

Tip 4: Watch for Mastectomy/Lymphadenectomy Unbundle

If the surgeon performs a mastectomy and lymphadenectomy during the same session, you should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19301 and 38745 separately.

Explanation: Often, with partial mastectomy, the surgeon will perform a limited axillary lymphadenectomy to remove some lymph nodes. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.
Sentinal lymph node biopsy

Look out for the "staged" exception:

Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time.

In such a case, you would report the lymphadenectomy as a staged procedure using 38745 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.

Visualization Is Separate With Sentinal Excision/Biopsy
If the operating surgeon (rather than a radiologist, for instance) performs visualization prior to biopsy or excision, you can report the visualization separately.
The surgeon may use either of two methods, or a combination of both, to identify a sentinal node:
1. Direct visualization (38792, Injection procedure; radioactive tracer for identification of sentinal node): The surgeon injects the vital dye (such as isosulfan blue) shortly before surgery to stain the lymphatic vessels that drain the tumor site, thereby allowing him to identify the sentinal node.
2. Lymphoscintigraphy (78195, Lymphatics and lymph nodes imaging): This nuclear medicine procedure involves injecting a radioisotope, such as technetium-99, under the skin several hours prior to surgery. The isotope acts as a radioactive "tracer," which the physician can map with a gamma camera as it flows into the sentinal node and its lymphatic channel and can detect in the OR with a hand-held device.
AMA guidelines set forth in CPT® Assistant (December 1999, Vol. 9, Issue 12) stipulate, "The injection of radioactive tracer is included in the lymphoscintigraphy procedure [78195] performed at the same session and is not reported separately. Therefore, it is inappropriate to report 38792 when lymphoscintigraphy is performed."
You would not report both 38792 and 78195 for the same patient during the same session because 78195 always includes 38792.
Payers may differ: Individual payers, including Medicare, may allow separate reimbursement for 38792 and 78195, however. Check your payers' local coverage determinations (LCDs) for more information.

Share this

Related Posts

Next Post »