General Surgery Coding Alert

Because a sentinel node biopsy includes not only removal of a portion of the lymph node, but also injection and imaging procedures, coding for it can be confusing. When billing for the procedure, surgeons should remember that each of these tasks were performed and should be submitted to the insurance carrier for payment.

To perform a sentinel node biopsy, the patient is injected with a radioactive isotope in a procedure called a lymphoscintigraphy several hours before the surgery to allow the surgeon to locate the sentinel nodes. In addition, blue dye is injected near the lymph node when the node-removal surgery begins, which allows the physician to visually pinpoint the nodes. The surgeon then may excise the node for biopsy (for more on the sentinel node biopsy procedure, see sidebar on page 42).

Coding the Procedures

According to CPT, code 38792 (injection procedure; lymphangiography for identification of sentinel node) is used to code the injection of the radioactive material and the blue dye, while the imaging component of the lymphoscintigraphy is coded 78195 (lymphatics and lymph glands imaging [for sentinal node injection, see 38792]). Each of the code descriptions specifically refers to the other, and both also indicate that the excision of the node identified should be coded 38500-38542. The question is: Does CPT imply that 78195 and 38792 can be coded together if the same physician performs both procedures?

The answer is no, says Cindy Parman, CPC, CPC-H, president of Coding Strategies Inc., a physician reimbursement consulting firm in Dallas, GA. According to Parman, the radiologist usually performs the lymphoscintigraphy, and he or she would bill 78195. The surgeon would charge 38792 only for the injection procedure. But if the same physician performs both procedures, only 78195 should be charged, according to Parman.

Nuclear medicine procedures must be performed following injection, ingestion or inhalation of the radiopharmaceutical [isotope], so a separate charge for the installation of the radioactive tracer may be considered unbundling by many payers, Parman says. Therefore, it may be inappropriate to assign both 38792 and 78195 for services performed by the same physician.

Parman urges coders to verify the policy with their local payers to ensure they use the correct codes, adding that payer information should be obtained in writing, and updated at least annually. This is always good advice, but in the case of a new technique like sentinel node biopsy, it can be crucial because new coding policies and guidelines for the services may be issued at any time.

Medicare Carrier Follows CPT Guidelines

Most Medicare carriers have yet to issue specific sentinel node policies, but on Nov. 1, 1999, such a policy went into effect in Pennsylvania. The coding guidelines from Xact Healthcare Professionals, the states Medicare carrier, state that: When lymphoscintigraphy is performed in advance of the surgical procedure to locate and mark the sentinel node(s), the injection and the lymphoscintigraphy procedures should be coded and reported separately by the physician performing these procedures. CPT code 38792 should be used for the injection procedure and code 78195 should be used for the lymphoscintigraphy. In other words, Xacts new policy does not bundle 78195 and 38792 when the procedures are performed by the same physician.

According to the Pennsylvania guidelines, however, the injection of vital dye to visualize the sentinel node in the operating room should be reported by the surgeon/physician who performs the injection using code 38792. This code should be reported only once for the injection of vital dye regardless of the number of injections made around the lesion ... When both a radioactive tracer and vital dye are used, reimbursement of CPT code 38792 will be made for both the injection of the radioactive tracer and the injection of the vital dye.
General surgeons should check with their local Medicare carrier to determine if similar sentinel node policies are in effect or planned.

Note: If the lymphoscintigraphy is performed by a radiologist, the surgeon would not be able to bill for the service.

More and more, hospitals are combining sentinel lymph node biopsies with full lymph node dissections in breast cancer cases, and many physicians expect that the technique, including lymphoscintigraphy, will become the
standard of care within the next few years.

But until new, more specific CPT codes clarify how these procedures should be billed, surgeons should check with their individual carrierswhether Medicare or third-party payerto determine how they want the service charged.