General Surgery Coding Alert

Don’t miss bilateral pay.

You’ve long had specific codes for open lymph node biopsies from various anatomic sites, but until this year, reporting inguinofemoral lymph node biopsies was a crapshoot.

All that changes with the addition of 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)) to CPT^® 2019.

Do this: Because 38531 fits into an existing system of related codes for lymph node biopsies and resections, you should follow our experts’ advice to avoid coding pitfalls and capture the pay you deserve for your surgeon’s inguinofemoral lymph node biopsy work.

Tip 1: Distinguish Site, Approach, and Scope

Proper 38531 use requires understanding how the surgeon removes the nodes, the anatomic site of the procedure, and the extent of lymph node removal from that site.

Site: The inguinofemoral region describes lymph nodes from the groin area and the femoral (upper thigh) area. Surgeons may commonly biopsy or resect nodes from this region for conditions such as lower abdominal, vulvar, or penile cancer.

Approach: Code 38531 describes an open lymph node excision, which involves an incision through skin and dissection down through tissues to access the lymph nodes. That means you should turn to a different code such as 38589 (Unlisted laparoscopy procedure, lymphatic system) if your surgeon performs a laparoscopic inguinal lymph node excision.

Scope: CPT^® provides several codes that describe removal of lymph nodes from the inguinofemoral region, so choosing the proper code means understanding the extent of the procedure. First, you need to know if the surgeon performed a resection or a biopsy.

“A lymphadenectomy is a radical resection, which means that the surgeon removes all or most of the nodes in an entire region,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, vice president for revenue management with Encounter Telehealth in Omaha, Nebr. “That’s different from a lymph node biopsy or excision, which means that the surgeon samples just one or a few lymph nodes from a region.”

That distinction makes a huge difference in your code selection. New-code 38531 describes an open inguinofemoral biopsy procedure, while the following codes describe various inguinofemoral resection procedures that are more extensive than the work of 38531:

• 38760 (Inguinofemoral lymphadenectomy, superficial, including Cloquet’s node (separate procedure))
• 38765 (… in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)).

Tip 2: Beware Bundled Services

The National Correct Coding Initiative (CCI) creates many procedure-to-procedure (PTP) code edits with 38531 to restrict improperly reporting other procedures with the new code.

Choose one: CCI lists 38531 as a column 2 code with the other CPT^® codes for inguinofemoral lymph node removal (38760 and 38765) with a modifier indicator of “0.” That means you should not report the codes together under any circumstances, but should instead select the single code that most accurately describes the surgeon’s work in removing lymph nodes from that region.

Local surgeries: CCI also bundles 38531 as a column 2 code with a “0” modifier indicator for several surgeries that occur in the iguinofemoral region and may typically involve excision of local lymph nodes. These include 54130-54135 (Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy…) and 56631, 56632, 56634, 56637, and 56640 (Vulvectomy, radical … with … inguinofemoral … lymphadenectomy).

“Notice that 38531 is a “separate procedure” code, which means you should report the code only when it describes a stand-alone procedure, not when the service is part of a larger procedure,” Joy explains.

Surgical package: Medicare prices newer CPT^® surgical codes, such as 38531, to include all the services in the surgical package, for example: infusions, punctures, blocks, heart/lung monitoring, radiology, etc. “That’s why CCI pairs 38531 with most of these ancillary services,” Joy explains.

Based on that reasoning, CCI lists 38531 as a column 1 code for the following services:

• Many closure codes such as 12001-12021 for simple repair, 12031-12057 for intermediate repair, and 13100-+13153 for complex repair
• Venipuncture, IV, infusion, or arterial puncture services represented by codes such as 36400-36406, 36420-36440, 36591-36592, 36600, and 36640
• Gastric tube or bladder catheter placement (43752, 51701-51703)
• Nerve blocks, such as most codes in the range 62320-64530 and 0213T-0230T
• Many electrocardiogram (ECG) procedures (93000-93010, 93040-93042)
• Multiple electroencephalography (EEG) services (95812-95822, 95829, 95955)
• Many respiratory assist and monitoring services (94002, 94200, 94250, 94680-94690, 94770)
• Intravenous push and hydration services like 96360-+96376
• Most E/M codes.

“Note that the bundles for nerve blocks and moderate sedation appear with a modifier indicator of ‘0,’ meaning that you can’t override the edit pairs under any circumstances,” Joy cautions.

Tip 3: Capture Bilateral Pay

If your surgeon samples left and right inguinofemoral lymph nodes, reporting just 38531 for the service will cost you pay. The national facility rate for 38531 is $454.09 (conversion factor 36.0391). That’s what your Medicare contractor will pay if you bill 38531.

But if your surgeon excised nodes from the left and the right, you should report 38531-50 (Bilateral procedure). Appending the modifier means that your Medicare contractor should pay 150 percent of the unilateral rate, or $681.14.

Bilateral: “You can always check the Medicare Physician Fee Schedule to see if you’re allowed to use the bilateral modifier with a specific code. A modifier indicator of ‘1’ in column Z means that you can use modifier 50 with the code,” Joy says.

Some payers may request that instead of using modifier 50, you bill two units of the code. “Commercial payers have different guidelines on when modifier 50 applies versus RT (Right side) and LT (Left side), so keep that in mind,” notes Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina. Alternatively, some payers may expect you to report 38531 x 2, or to report a single unit of 38531 on two separate claim lines.

Regardless of the reporting mechanism, you should expect payment of one and a half times what you would receive if the surgeon removed nodes from just one side.