General Surgery Coding Alert

When to Report Biopsy Separately

Question: We often perform sentinel node biopsy and, if the frozen section of that node shows cancer, we proceed with the axillary lymphadenectomy at the same time.

The August 2006 General Surgery Coding Alert instructed: -You should not separately report sentinel node biopsy and lymphadenectomy 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.-

Performing the sentinel node biopsy is a delicate, time-consuming process. Then we must wait for a frozen section. How can we be reimbursed for the effort of the sentinel node biopsy when this precedes the lymphadenectomy at the same session?

Virginia Subscriber
 
Answer: CMS rules can be confusing, but you can report sentinel node biopsy (38500-38530) separately from lymphadenectomy (38700-38780) -- even if the two occurduring the same operative session.
 
Medicare guidelines stipulate that you may report the biopsy separately if the results of the biopsy lead to the decision to perform the lymph node removal. National Correct Coding Initiative guidelines state, -Sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy with or without lymphadenectomy.-

As you point out, this would be the case the vast majority of cases --  after all, the point of the biopsy is to avoid further excision, if possible.

Therefore, if your surgeon performed a sentinel node biopsy as outlined in your question and, based on the results of that biopsy, performed a same-day lymphadenectomy, you may report both procedures.

Many payers will require that you append modifier 59 (Distinct procedural service) to the appropriate biopsy code (38500-38530) to further differentiate the procedure from the follow-up lymphadenectomy. In addition, your documentation should make clear that the biopsy results provided the justification for and led to the decision to perform the subsequent excisions.

The problem: Confusion arises because Medicare payer rules also stipulate that you should not report a separate node biopsy if the surgeon prospectively plans the lympha-denectomy. Typical payer language explains, -Sentinel lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy].-

In other words, if the surgeon is going to remove the lymph nodes regardless of the results of the biopsy (a clinically unlikely scenario), you can't charge separately for sentinel node biopsy.

Bottom line: You can report both sentinel lymph node biopsy and lymphadenectomy as long as the lymphadenectomy is unplanned at the time of the biopsy and the decision to perform lymphadenectomy (at the same or a later session) is based on the results of the biopsy.