Ob-Gyn Coding Alert

A major proponent of sentinel node biopsy for breast cancer patients has released a new study that underscores the procedure's effectiveness. The report, presented at a meeting of the Federation of European Cancer Societies by Dr. Umberto Veronesi, a pioneer in breast-cancer surgery, advocates the use of sentinel node biopsy as a less radical alternative to removal of all the lymph glands in the armpit.
 
In traditional breast-cancer surgery (19100-19272), the surgeon removes all the lymph glands in the armpit to determine if the cancer has spread. For many women, the result is lymphedema or painful swelling in the affected arm that can lead to disability and recurrent infection. Still, because of the high rate of metastases in breast cancer, lymph-gland removal and the associated risks have long been considered a "necessary evil" to stop cancer from spreading.
 
Sentinel node biopsy involves identifying and removing only the sentinel node or gland from the armpit. The sentinel is the first node that will be invaded by cancer. The theory is that by removing only the sentinel node and running a biopsy on it, pathology can determine whether the cancer has spread before removing all the lymph glands. If no cancer is present in the sentinel node, the other glands stay. If cancer, even in its earliest stages, is present in the sentinel node, the other lymph glands are removed.

Coding the Procedure
 
 
Coding for sentinel node biopsy is not as contentious as the debate about the procedure itself. For the ob/gyn injecting the isotope, 38792 (injection procedure; for identification of sentinel node) is used for the injection of the radioactive material and the blue dye. The imaging component of the procedure, 78195 (lymphatics and lymph glands imaging [for sentinel node identification, use 38792]), will almost always be coded by the radiologist. The excision of the node is coded 38500-38530 (biopsy or excision of lymph node ...) depending on the method of excision.
 
To perform the procedure, the physician injects the patient with a radioactive isotope several hours before the surgery, in a procedure called a lymphoscintigraphy (38792). This isotope travels through the tissue and finds the sentinel node. Blue dye injected in the lymph-node area allows the physician to visualize and excise the node for biopsy.
 
Proponents of sentinel node biopsy argue in favor of this more conservative approach to treating breast-cancer patients, one that can save lymph glands in the majority of patients in which the cancer has not spread. In Veronesi's four-year study of a group of women who underwent sentinel node biopsy in lieu of full lymph-gland removal, all were still cancer-free without enduring the pain and complications of total lymph-node removal. Other cancer experts feel that sentinel node biopsy is still too new and unproven a procedure to warrant widespread use. Human error is always a factor and there is the risk of removing the wrong node, as well as missing the metastases.
 
Because sentinel node biopsy is still considered experimental by many carriers, preauthorization is essential before performing the procedure. Find out from the carrier which code it requires and obtain that information in writing. Because the procedure appears to be gaining wider acceptance in the medical community, reimbursement should ease. But coders can rest assured that will be a slow process as coding seldom keeps an even pace with technological and medical advances.