General Surgery Coding Alert
Want to Improve Coding Accuracy for Sentinel Node Biopsies? Count Incisions, Not Excisions
Although it may seem counterintuitive, you don't bill for sentinel node biopsies according to the number of biopsies the surgeon performs. And, to code properly you must be aware of payer guidelines that limit the use of this technique to exclude certain patients or tumors above a given size. 'Sentinel' Node Provides Early-Warning System Sentinel lymph node biopsy "is a technique that allows sampling of the lymph node or nodes that receive drainage directly from a tumor or an area of carcinoma," according to Medicare guidelines. In other words, such biopsies allow the surgeon to determine if a cancer has spread to the most likely lymphatic drainage area or if it is contained at the primary location. The advantage of this technique is that if the sentinel lymph node is negative for metastases, the surgeon need not perform a complete axillary lymphadenectomy, thereby avoiding the morbidity and complications associated with that procedure. Incisions, Not Biopsies, Determine Coding When reporting more than one biopsy, you should keep in mind that the number of incisions not the number of biopsies determines the number of codes and/or units. That is, 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. When reporting more than one biopsy code, append modifier -59 (Distinct procedural service) to the second and subsequent codes. Consider Indications and Limitations Insurers allow reimbursement for sentinel node biopsy for a fairly limited number of diagnoses, and you must always code to the highest level of specificity. Typically, insurers will deny claims with "truncated" diagnoses. Medicare sets the standard, allowing ICD-9 code ranges 172.0-172.9 (Malignant melanoma of skin), 174.0-174.9 (Malignant neoplasm of female breast) and 175.0-175.9 (Malignant neoplasm of male breast). And, "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 (which is typical of other Medicare carrier's guidelines). When It's Not Covered Medicare (and other payers) specifically note that sentinel node biopsy is not covered if As the above guidelines suggest, if the physician plans and performs a lymphadenectomy (38740-38745) during the same operative session, the sentinel node biopsy(s) is not separately reportable.
The sentinel node biopsy occurs in two steps, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc., and chief billing officer for the University of Illinois Hospital physicians in Chicago. First, the physician must identify the sentinel node using one or a combination of separately reportable visualization procedures (See "Visualize Better Payment for Sentinel Node Biopsy Procedures," General Surgery Coding Alert, June 2003). After the surgeon has located and marked the node, he or she proceeds with the biopsy itself. CPT provides, and payers observe, several codes to describe the excision, depending on the depth and location of the node:
For 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, Church says. 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.
Empire's LMRP also specifies that sentinel lymph biopsy may be indicated in breast carcinoma. The payer will also reimburse such procedures for clinical stage I and II breast carcinoma with no palpable axilla lymph nodes.
1. clinically suspicious axillary nodes are present,
2. the tumor is greater than 5.0 cm,
3. the patient is pregnant and a radioactive tracer is used (may be performed with a vital dye), or
4. there are multifocal lesions.
General Surgery Coding Alert
- Part 2:
Want to Improve Coding Accuracy for Sentinel Node Biopsies? Count Incisions, Not Excisions
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