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General Surgery Coding Alert

CMS Revises Mastectomy and Sentinel Node Biopsy Policy

Published on Thu Oct 28, 2004

NCCI 10.3 instructs surgeons to report 38500, 38525-38530 with 19160

If you've strictly adhered to CMS' recommendation to report 38740 (Axillary lymphadenectomy; superficial) for sentinel node biopsy in conjunction with partial mastectomy 19160 (Mastectomy, partial), get ready to adjust your coding.

The latest edition of the National Correct Coding Initiative (NCCI) contains revised text instructing surgeons to report excision codes 38500 or 38525-38530, as appropriate, for sentinel node biopsy with 19160.

The new text, which appears in the NCCI introduction to surgery codes 30000-39599, instructs, "sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy with or without lymphadenectomy."

The text specifies that surgeons should report open biopsy or excision of sentinel lymph node(s) as follows:

  • Axillary: 38500, Biopsy or excision of lymph node(s); open, superficial; or 38525, ... open, deep axillary node(s)

  • Deep cervical: 38520, ... open, deep cervical node(s) with excision scalene fat pad

  • Internal mammary: 38530, ... open, internal mammary node(s).

    Payment alert: The revision in CMS policy may mean less reimbursement for general surgeons because 38740 reimburses at a higher rate than 38500 or 38520-38530. From a coding perspective, however, the change makes sense: Biopsy of lymph node(s) as performed with partial mastectomy differs clinically from lymphaden-ectomy as described by 38740.

    The NCCI's medical director, Niles Rosen, MD, has stated that the prior instruction to report 38740 for sentinel lymph node biopsy "was based on incorrect information." At this point, however, there are no indications that CMS will make the changes retroactive to claims filed previous to Oct. 1, 2004.

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