Oncology & Hematology Coding Alert

To capture appropriate reimbursement for a sentinel lymph node biopsy, surgical oncology coders need to be familiar with the components of the procedure. Sentinel node biopsies are an increasingly common tool to determine the staging and progression of cancer in oncology patients. Oncologists will biopsy this sentinel node to determine if the cancer has spread or is contained at the primary location.

How Is Sentinel Lymph Node Biopsy Performed?

The sentinel"" node is the first lymph node to receive drainage from a cancer-containing area of the breast. Sentinel lymph node biopsy involves identification" removal and evaluation of lymph nodes that drain the area of a malignant tumor. Identification of the sentinel node involves complicated coding. Two methods or a combination of both are used to identify a sentinel node:
 

Direct visualization of vital dye e.g. isosulfan blue. Direct visualization involves the injection of vital dye shortly before surgery to stain the lymphatic vessels that drain the tumor site which further helps to identify a sentinel node
 

Lymphoscintigraphy which is a nuclear medicine procedure that involves injecting a radioisotope such as technetium-99 under the skin hours before surgery. The isotope acts as a radioactive "tracer" as it flows into the sentinel node and its lymphatic channel.

Breast Cancer: A Clinical Example

During a routine mammogram a lump is found in the right breast of a 64-year-old woman. The mass is biopsied found to be malignant and removed. To determine if the cancer metastasized the oncology surgeon also performs a sentinel node biopsy.

A preoperative lymphoscintigraphy allows the radiologist to assess lymphatic drainage.

A radioactive tracer is injected and the lymphatic system is imaged using a gamma camera. The sentinel node can be marked for the surgeon says Donna J. Richmond RCC CPC of Acadiana Computer Systems Inc. a billing practice management software and services and consulting company based in Lafayette La. The code for this procedure typically submitted by the radiologist is 78195 (Lymphatics and lymph nodes imaging). Richmond clarifies that the hand-held gamma detector is usually used in surgery and would be included in the biopsy code. "78195 includes the injection of a radiopharmaceutical and imaging. If no imaging is done then 78195 is not used and 38792 (Injection procedure; for identification of sentinel node ) would be coded for the injection of the radioactive material."

The cancer site is then injected with isosulfan blue dye to further assist the oncology surgeon in locating the sentinel node. Code 38792 is used to report this service.

According to Richmond a combination of both blue dye and the gamma probe is often used to identify the sentinel node. The oncology surgeon excises the sentinel node or nodes for analysis by the pathologist. The biopsy or excision of the sentinel node is reported using the appropriate code based on the location of the node. The most common codes are 38500 (... superficial) 38525 (... deep axillary node[s]) or 38530 (... internal mammary node[s]).

When the sentinel node is identified it is excised and sent for evaluation. Many carriers prefer a combination of vital dye and radioactive tracer to identify the sentinel node(s) both visually and by lymphoscintigraphy. If the oncology surgeon performs the sentinel node excision but did not inject the dye or radiopharmaceutical tracer only the excision code (38500-38542) should be billed.

Pathology codes include a microscopic examination reported by the pathologist as 88305. If the result of the sentinel node biopsy is positive at this point the pathologist advises the oncologist of these findings. More often than not in this situation the surgical oncologist will proceed with an axillary dissection during the same surgical session. The tumor is also removed at the same time. "The sentinel node biopsy is most frequently done at the same time as the primary breast cancer surgery " says Margaret M. Hickey MS MSN RN OCN CORLN an independent coding consultant in New Orleans. "However this may not always be the case."

Sentinel node biopsy is not covered for all breast-cancer patients. Common limitations for the procedure include these indications: clinically suspicious axillary nodes tumors greater than 5.0 cm the patient is pregnant and a radioactive tracer is used there are multifocal lesions.

Coding for Sentinel Nodes

Although there are differences among carriers a consensus on billing such claims with the following codes is taking shape Richmond says:

38500 Biopsy or excision of lymph node(s); open superficial

38505 ... by needle superficial e.g. cervical inguinal axillary)

38510 ... open deep cervical node(s)

38520 ... open deep cervical node(s) with excision scalene fat pad

38525 ... open deep axillary node(s)

38530 ... open internal mammary node(s)

38542 Dissection deep jugular node(s)

38792 Injection procedure; for identification of sentinel node

78195 Lymphatics and lymph nodes imaging.

CPT notes that the old code 35840 (Exploration for post-operative hemorrhage thrombosis or infection; abdomen) has been deleted.

If a second sentinel node is excised from a different site through a different incision the appropriate excision code may be reported appended with modifier -59 (Distinct procedural service) to indicate that it is distinct from the first excision and should be separately paid. However if the sentinel node biopsy is performed during the same session as an axillary node dissection it should not be reported separately.

The service is covered when the patient has "clinical stage I and II carcinoma of the breast with no palpable lymph nodes in the axilla " according to an Empire Medicare Services sentinel node local medical review policy (LMRP) updated in June 2002.

Empire also allows sentinel node biopsy to accompany surgery for vulval carcinoma (184.4) if it is clinical stage I or II. The same LMRP severely warns against using truncated codes. The following ICD-9 codes are associated with diagnoses for which sentinel node biopsies are used and reimbursable:

172.0-172.9 Malignant melanoma of skin

174.0-174.9 Malignant neoplasm of female breast

175.0-175.9 ... of male breast

 

184.4 Malignant neoplasm of vulva unspecified.

Richmond urges coders to check with their local payers to ensure use of the correct codes. Obtain the information in writing and update it annually.