General Surgery Coding Alert
Solutions for Common Coding Dilemmas
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1. The surgeon performed a breast biopsy followed by a modified radical mastectomy. How do I select the right breast biopsy codes? Is the biopsy bundled with the mastectomy?
Many biopsy codes are bundled with lumpectomy and mastectomy codes in the national Correct Coding Initiative (CCI). But this does not mean they cannot be billed together, says Elaine Elliott, CPC, an independent general surgery coding and reimbursement specialist in Jensen Beach, Fla.
The CCI edits do not apply when the biopsy is diagnostic, i.e., the biopsy leads to the decision to perform the larger procedure. If the results of a biopsy are positive, for example, the surgeon may perform a lumpectomy or mastectomy. In such cases the biopsy is not included in the lumpectomy or mastectomy and is separately payable. But if the surgeon -- having previously performed a biopsy -- plans to remove a malignant mass but wants a confirmatory biopsy, this second biopsy is a component of the larger procedure and may not be billed separately.
Breast biopsies differ depending on the kind of tissue excised and the method used. Applicable codes include:
The first step when coding is to determine if the biopsy is bundled with the larger excision code. For example, an excisional biopsy (19120) returns positive. After conferring with the patient, the surgeon performs a modified radical mastectomy, 19240 (mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).
CCI bundles 19120 to 19240. The edit includes a 1" indicator however which means it can be bypassed by appending a modifier under certain circumstances. For instance if the surgeon's documentation indicates that the biopsy results led to the decision to perform the mastectomy the excisional biopsy is separately payable.
Most Medicare carriers want modifier -58 (staged or related procedure or service by the same physician during the postoperative period) appended to the primary procedure. This indicates that the second procedure was planned prospectively at the time of the original procedure and that it is "more extensive than the original." Other carriers require that modifier -59 (distinct procedural service) be appended. CPT specifically states however that modifier -59 should be used "only if no more descriptive modifier is available."
Therefore unless the carrier indicates otherwise the procedures should be coded 19120 19240-58.
Note: Some breast biopsy codes (for example 19100) have zero global days. When such biopsies are followed by a more extensive procedure on a different day do not use a modifier.
2. Can the surgeon bill an intraoperative lymphoscintigraphy with a sentinel node biopsy?
No. Imaging services are paid only with a lymphoscintigraphy that includes images obtained in the nuclear lab says Cindy Parman CPC a radiology coding and reimbursement specialist member of the American Academy of Professional Coders' national advisory board and president of Coding Strategies Inc. in Dallas Ga. When the surgeon performs "intraoperative lymphoscintigraphy" using a gamma probe during the sentinel node biopsy to image a radioisotope injected earlier the imaging is included in the biopsy excision procedure.
Sentinel lymph node biopsy involves identification removal and evaluation of lymph nodes that drain the area of a malignant tumor. Identifying the sentinel node (rather than the biopsy) often complicates coding.
Two methods or a combination of both are used to identify a sentinel node:
Lymphoscintigraphy is a nuclear medicine procedure that involves injecting a radioisotope such as technetium under the skin hours before surgery. The isotope acts as a radioactive "tracer" as it flows into the sentinel node and its lymphatic channel. Direct visualization involves the injection of vital dye shortly before surgery to stain the lymphatic vessels that drain the tumor site which further helps to identify a sentinel node. Usually this procedure is performed with one of two types of lymphoscintigraphy:
Coding for Sentinel Nodes
When the sentinel node is identified it is excised and sent for evaluation. Many carriers prefer a combination of vital dye and radioactive tracer to identify the sentinel node(s) both visually and by lymphoscintigraphy.
Although there are differences among carriers a consensus on billing such claims involving the following codes is taking shape:
Code 78195 is used when the physician (a radiologist or a surgeon trained in nuclear procedures) performs both injection of the radiopharmaceutical tracer and interpretation of the images. This is a complete lymphoscintigraphy.
Insurers may not reimburse 78195 and 38792 together if the procedures are performed by the same physician.
"Nuclear medicine procedures must follow injection ingestion or inhalation of the radiopharmaceutical [isotope]. A separate charge for the tracer may be considered unbundling " Parman says.
When the same physician performs injection and imaging bill 78195. Report 38792 for the injection only.
Code 38792 may be billed by both the surgeon and the radiologist during the same session if the radiologist injected the tracer but did not obtain any images and the surgeon injected only the blue dye says Susan Callaway CPC CCS-P an independent coding and reimbursement specialist and educator in North Augusta S.C.
Note: Some carriers may not reimburse claims for 38792 by two physicians on the same day. And some carriers such as WPS the local Medicare Part B carrier in Illinois Michigan and Wisconsin do not pay separately for the injection.
The surgeon may not bill separately for images obtained during surgery using a handheld gamma probe (i.e. an intraoperative lymphoscintigraphy) because the imaging is included in the appropriate biopsy procedure (38500-38525).
If the surgeon performs the sentinel node excision but did not inject the dye or radiopharmaceutical tracer only the excision code (38500-38542) should be billed.
Occasionally a general surgeon may perform all the components of the lymphoscintigraphy in the radiology department and a few hours later inject the blue dye and excise the sentinel lymph node. Some carriers may allow the surgeon to bill both sessions:
Session 1: radiology department
Session 2: operating room
Modifier -59 should be appended to 38792 to indicate that the injection was for the blue dye not the radioisotope and that 38792 was performed during a later session. Support modifier -59 by including an entry in the "comment" box of the claim form that notes the times of the injections of the radiopharmaceutical tracer and the blue dye.
Also if the surgeon performed the complete lymphoscintigraphy (injection and imaging) he or she should dictate a separate radiologic report to bill 78195.
Note: If a second sentinel node is excised from a different site through a different incision the appropriate excision code may be reported appended with modifier -59 to indicate it is distinct from the first excision and should be separately paid. However if the sentinel node biopsy is performed during the same session as an axillary node dissection it should not be reported separately.
Sentinel node biopsy is not indicated and therefore not covered for all breast-cancer patients. The service is covered when the patient has "clinical stage I breast carcinoma stage I or II with no palpable lymph nodes in the axilla " according to a WPS sentinel-node local medical review policy.
Note: Clinical stage I or II malignant melanoma of the skin is also a covered indication.
WPS also instructs physicians to document that the tumor is in clinical stage I or II if one of several ICD-9 codes is linked to the procedure. Among these are:
Parman urges coders to check with their local payers to ensure use of the correct codes. Obtain the information in writing and update it annually.
3. How should I code a lumpectomy? The word does not appear in CPT. How does a lumpectomy differ from a partial mastectomy?
The correct code for a lumpectomy is 19120 (excision of cyst fibroadenoma or other benign or malignant tumor aberrant breast tissue duct lesion nipple or areolar lesion [except 19140 mastectomy for gynecomastia] open male or female one or more lesions) says Marcella Bucknam CPC billing and compliance manager with the department of surgery at the University of Nebraska in Omaha. The real issue is whether 19120 should be billed or if the procedure performed would be more correctly reported using a partial mastectomy code (e.g. 19160 mastectomy partial).
"If the surgeon refers to the procedure as 'lumpectomy ' it's probably a 19120 " Bucknam says. "A lumpectomy involves removing a lump and some surrounding tissue (the margins). A partial mastectomy however involves removing all the material in a certain part of the breast."
The physician's intent should not influence the choice of code Bucknam adds. Even though a margin of tissue is routinely removed when performing a lumpectomy some surgeons believe that such tissue removal automatically qualifies the procedure as a partial mastectomy. For example the surgeon might maintain that if a biopsy has already been taken and returns malignant the lesion should be excised with clean tissue margins all the way around and at that point the procedure should be billed as a partial mastectomy.
But this is not necessarily correct. Although the surgeon ultimately determines whether a procedure should be considered a lumpectomy or partial mastectomy the size of the lump relative to the size of the patient's breast must be considered. Although the short CPT descriptor does not mention how much tissue must be removed before 19160 can be charged generally at least 25 percent of the patient's breast must be removed to bill a partial mastectomy.
For example the Coders' Desk Reference states that 19160 "is often referred to as a segmental mastectomy or quadrantectomy " which implies that a quarter of the patient's breast tissue should be removed to bill 19160 appropriately.
Note: If the patient's breast is visibly altered or deformed as a result of the procedure it is likely that more than a lump was removed.
Partial Mastectomy or Lumpectomy?
Instead of determining if the excision meets the requirements for a partial mastectomy Bucknam focuses on the lumpectomy. "I ask 'Does the procedure as documented meet or exceed the requirements for a lumpectomy?' In other words was more than a lump and surrounding tissue removed? If so a partial mastectomy was probably performed. Otherwise it's a 19120."
Bucknam notes that in some cases a lumpectomy is begun but because the margins of the mass extend quite far the surgeon cuts further than he or she normally would to be sure all malignant tissue has been excised. In some cases more than a quadrant (25 percent) of the breast has been removed (i.e. a partial mastectomy) which is appropriately reported using 19160.
Often surgeons make two excisions. The first is coded 19120 because most surgeons take a margin of tissue so that another excision will not be necessary if the biopsy returns positive (malignant). If the margins subsequently return positive (meaning the tumor now exists beyond the excised tissue) a wider excision (partial mastectomy) may be performed often with axillary lymph node dissection.
Note: When axillary lymph nodes are removed during a partial mastectomy report 19162 (mastectomy partial; with axillary lymphadenectomy). If the lymphadenectomy is performed with a lumpectomy 19162 does not apply. Instead 38745 (axillary lymphadenectomy; complete) should be billed in addition to 19120. Furthermore if the surgeon returns during the postoperative period of the partial mastectomy or lumpectomy to examine the patient for lymph node involvement and subsequently removes the nodes 38745 should be billed with modifier -58 appended. If the final pathology report from the lumpectomy returns with positive margins and the surgeon performs a wider excision and node dissection a few weeks later bill 19162-58.
These guidelines may not apply to all carriers. Local Medicare Part B carriers determine their own policies on many services and policies among carriers can be surprisingly different. Commercial payers meanwhile may follow a different fee schedule and guidelines.
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