General Surgery Coding Alert

What you need to get paid for lymph excisions in combination with other breast tissue excisions

Sentinel node biopsy is not the same as lymphadenectomy, and confusing the two could have dire 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: Include Same-Session Sentinel Excision in Lymphadenectomy

You should not separately report sentinel node biopsy (38500-38530) and lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinel node biopsy in the more extensive, planned, same-location lymphadenectomy.
 
Here's what Medicare says: -Sentinel lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy],- says Empire Medicare Service's local medical review policy (LMRP) for New York and New Jersey (this policy is typical of other Medicare carrier guidelines).
 
Example: The surgeon performs a complete axillary lymphadenectomy (38745) to remove the lymph nodes between the pectoralis major and the pectoralis minor muscles. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinel nodes (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). You should therefore report 38745 only, in this case.

Tip 2: Prior Sentinel Excisions Are Separate

When the surgeon performs a sentinel 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 sentinel node biopsy separately, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, charge capture manager at University of Washington Physicians.
 
-This would be billable,- Bucknam says, -just like a breast biopsy is billable when the decision to do the partial mastectomy or other treatment is based on the results of the biopsy.-

Specificity Identifies Sentinel Node Biopsy

You should consider sentinel node biopsy (38500-38530) to be a more -targeted- procedure than lymphadenectomy (38700-38780), says M. Trayser Dunaway, MD, FACS, CSP, CHCO, a surgeon, physician and coding innovator, and healthcare consultant in Camden, S.C.
 
-Removing the sentinel nodes is a less-invasive procedure,- he says.
 
The sentinel node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other site). The advantage of this technique is that if the sentinel 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.

CMS goes on record: -Sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy with or without lymphadenectomy,- according to guidelines set forth in the introductory text of the National Correct Coding Initiative. The text specifically instructs surgeons to report 38500 or 38525-38530, as appropriate, for sentinel node biopsy with 19160 (Mastectomy, partial).
 
Example: The surgeon takes a biopsy of the sentinel axillary node (38500, ... open, superficial). The pathology report indicates that the malignancy has spread, so the surgeon follows up several days later with a partial mastectomy to remove the affected tissue.
 
Because the biopsy led to the decision to perform the mastectomy, you may report both 38500 and 19160.

Tip 3: Count Incisions, Not Biopsies

When the surgeon performs more than one sentinel node biopsy, you should realize that the number of incisions -- not the number of biopsies -- determines the number of codes and/or units, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, a surgeon, physician and coding innovator, and healthcare consultant in Camden, S.C.
 
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.

Visualization May Be Separate

If your 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 sentinel node.
 
1. Direct visualization (38792, Injection procedure; for identification of sentinel 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 sentinel 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 can be mapped by a gamma camera as it flows into the sentinel node and its lymphatic channel and is detected in the OR by a handheld 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.-
 
In other words: You would not report both 38792 and 78195 for the same patient during the same session: 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 for more information.

Tip 4: Watch for Unbundling

If the surgeon performs a mastectomy and lyphadenectomy during the same session, you should report 19162 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19160 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, Dunaway says.
 
Look out for the -staged- exception: Following some partial mastectomies (19160), 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 appended with modifier 58 (Staged procedure).