Radiology Coding Alert

Following CPT guidelines could be costing you money

The AMA and CPT tell you not to report 38792 and 78195 during the same session, but you could be throwing away hard-earned dollars if you don't check with your payer first. Here's how to code for sentinel node injections when your payer leaves CPT Codes rules by the wayside.

Take Advantage of Your Payer's Policy

When a physician wants to know whether a patient's cancer has metastasized, he will often order a sentinel node injection and biopsy, says Bruce Hammond, CRA, CMNT, chief operating officer of Diagnostic Health Services in Texas. The sentinel node is the first in a chain of lymph nodes that receives lymphatic fluid draining from the tumor site.
 
The physician injects radioactive material (38792, Injection procedure; for identification of sentinel node) making the sentinel node (and possibly others) radioactive if the cancer has spread to the node. The physician may also order imaging of the site, using a nuclear medicine procedure called lymphoscintigraphy (78195, Lymphatics and lymph nodes imaging).

Opportunity: Individual payers, including certain Medicare carriers, may allow separate reimbursement for 38792 and 78195, regardless of CPT's instructions - and this is an opportunity you don't want to miss. Reporting 38792 can bring in an additional $38.66, before adjusting for geography.
 
For instance, Empire Medicare Services, the local Part B carrier for New York, specifies, "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" [emphasis added]. The Empire policy states that you should report 38792 for the injection procedure, and report 78195 for the lymphoscintigraphy.
 
Experts warn: You should look for documentation stating whether or not the radiologist or tech actually imaged the site to determine if you may code for this service. Some facilities choose not to image and instead use a probe to sweep over the area to locate the radioactive node for excision, Hammond says. If you don't see documentation of imaging, only report injection code 38792.

Moneymaker: Empire's sentinel node biopsy policy also explains, "The injection code (38792) may be billed with NOS of 001 each for the injection of the radioactive tracer and the injection of the vital dye, regardless of the number of actual injections for each substance. If one physician injects both the radioactive tracer and the vital dye, then the services may be billed on one line on the claim, with a NOS of 002."

Translation: For this payer, you may report 38792 twice - once for injection of the isotope and once for injection of the dye for direct visualization. Snag: If the physician makes four separate injections of one substance, you may report only a single unit of 38792.

Note: You can access this local policy on-line at www.ghimedicare.com/provider/DOWNLOAD/jun02-41.html.

Set Your Eyes on CPT

If your payer points you to CPT guidelines, follow these rules for the perfect claim.

Reality: Do not report 38792 for the injection procedure if the physician performs imaging during the same session and you are confined by CPT guidelines, says Tammy McMillan, RCC, coding supervisor and reimbursement specialist for Radiology Associates PA in Little Rock, Ark.

Reason: Imaging code 78195 includes the injection procedure, so you shouldn't report 38792 if the same physician performs both the injection and imaging, she adds, citing the CPT rule. Only report 78195

Don't miss: If the patient has a nuclear medicine scan one day and then returns on another day for a dye injection and node excision, you may report the dye injection for that second visit because it is not considered a component of the previous imaging procedure.

Lesson learned: If you don't want to forfeit legitimate reimbursement, always check your payers' policies prior to billing these procedures. Automatically following CPT's suggested guidelines in this case can lead to money down the drain.