Outpatient Facility Coding Alert

Prevent unexpected denials by keeping an eye out for bundled services.

When 2019 arrived, it introduced a brand new, and especially useful, code for the reporting of inguinofemoral lymph node biopsies. With the addition of 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)) to the CPT^® manual, you’ve no longer got to think outside the box when reporting these nuanced procedures.

But as you’re all too familiar, with new codes come new responsibilities.

Read on for some expert advice to steer you clear of any potential pitfalls with 38531 reporting.

Tip 1: Distinguish Site, Approach, and Scope

Proper 38531 use requires understanding how the surgeon removes the nodes, the anatomic site of the procedure, and the extent of lymph node removal from that site.

Site:  The inguinofemoral region describes lymph nodes from the groin area and the femoral (upper thigh) area. Surgeons may commonly biopsy or resect nodes from this region for conditions such as lower abdominal, vulvar, or penile cancer.

Approach:  Code 38531 describes an open lymph node excision, which involves an incision through skin and dissection down through tissues to access the lymph nodes. That means you should turn to a different code such as 38589 (Unlisted laparoscopy procedure, lymphatic system) if your surgeon performs a laparoscopic inguinal lymph node excision.

Scope: CPT^® provides several codes that describe removal of lymph nodes from the inguinofemoral region, so choosing the proper code means understanding the extent of the procedure. First, you need to know if the surgeon performed a resection or a biopsy.

“A lymphadenectomy is a radical resection, which means that the surgeon removes all or most of the nodes in an entire region,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, vice president for revenue management with Encounter Telehealth in Omaha, Nebraska. “That’s different from a lymph node biopsy or excision, which means that the surgeon samples just one or a few lymph nodes from a region.”

That distinction makes a huge difference in your code selection. New code 38531 describes an open inguinofemoral biopsy procedure, while the following codes describe various inguinofemoral resection procedures that are more extensive than the work of 38531:

• 38760 —Inguinofemoral lymphadenectomy, superficial, including Cloquet’s node (separate procedure)
• 38765 — … in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure).

Tip 2: Beware Bundled Services

The National Correct Coding Initiative (NCCI, or CCI) creates many procedure-to-procedure (PTP) code edits with 38531 to restrict improperly reporting other procedures with the new code.

Choose one: CCI lists 38531 as a column 2 code with the other CPT^® codes for inguinofemoral lymph node removal (38760 and 38765) with a modifier indicator of “0.” That means you should not report the codes together under any circumstances, but should instead select the single code that most accurately describes the surgeon’s work in removing lymph nodes from that region.

Local surgeries: CCI also bundles 38531 as a column 2 code with a “0” modifier indicator for several surgeries that occur in the inguinofemoral region and may typically involve excision of local lymph nodes. These include 54130-54135 (Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy…) and 56631, 56632, 56634, 56637, and 56640 (Vulvectomy, radical … with … inguinofemoral … lymphadenectomy).

Surgical package: Medicare prices newer CPT^® surgical codes, such as 38531, to include all the services in the surgical package, for example: infusions, punctures, blocks, heart/lung monitoring, radiology, etc. “That’s why CCI pairs 38531 with most of these ancillary services,” Joy explains.

Based on that reasoning, CCI lists 38531 as a column 1 code for the following services:

• Many closure codes such as 12001-12021 for simple repair, 12031-12057 for intermediate repair, and 13100-+13153 for complex repair.
• Venipuncture, IV, infusion, or arterial puncture services represented by codes such as 36400-36406, 36420-36440, 36591-36592, 36600, and 36640.
• Gastric tube or bladder catheter placement (43752, 51701-51703).
• Nerve blocks, such as most codes in the range 62320-64530 and 0213T-0230T.
• Many electrocardiogram (ECG) procedures (93000-93010, 93040-93042).
• Multiple electroencephalography (EEG) services (95812-95822, 95829, 95955).
• Many respiratory assist and monitoring services (94002, 94200, 94250, 94680-94690, 94770).
• Intravenous push and hydration services like 96360-+96376.
• Most E/M codes.

“Note that the bundles for nerve blocks and moderate sedation appear with a modifier indicator of ‘0,’ meaning that you can’t override the edit pairs under any circumstances,” Joy cautions.

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