Radiology Coding Alert

Read the fine print on payer policies to avoid unexpected bundling frustration

Sentinel node injection and imaging sounds simple enough, but toss in multiple injections, substances, and imaging techniques, and you've got a recipe for a potential coding disaster.

Simplify your task with these expert tips on applying the proper codes to the different sentinel node injection and imaging scenarios you may face. Catch This Injection Unit Tip, Net an Extra $38 Sentinel node injection begins with the provider injecting a radioactive tracer near the tumor site. The tracer flows with the lymphatic fluid into the lymph nodes that are "downstream" from the tumor. The sentinel node is the first node in the chain, which makes it most likely to contain malignant cells if the cancer has spread.

The sentinel node absorbs the tracer, making it easy for the physician to locate it, says experienced radiology coder Stacy Gregory, RCC, CPC, of Tacoma, Wash.-based Gregory Medical Consulting Services.

Relevant code: The code that describes this injection procedure is 38792 (Injection procedure; for identification of sentinel node), which pays about $38.

Count units: Your payer may allow you to report a tracer injection and a dye injection separately. Example: Empire's sentinel node biopsy policy explains that you may report 38792 on two lines, one unit each, when one physician injects both the radioactive tracer and the vital dye. The key is that you report one unit per substance injected rather than one unit per injection. If the physician makes four separate tracer injections and does not inject the dye, you would report only one unit (see the LCD at www.empiremedicare.com/newypolicy/policy/l3473_final_guideline.htm).
 
Be on Guard If your physician provides one 38792 service, and a surgeon provides a second 38792 on the same day, the payer will typically pay the first claim it receives and deny the second, Gregory says. Watch for the denial and appeal it with an explanation of the service.

Caution: You'll likely find that your payer bundles 38792 into the procedure described below. Watch This Imaging Bundle Pitfall Typically, the nuclear provider follows injection with lymphoscintigraphy. The provider uses a gamma camera to get dynamic, real-time images to map the tracer's path and sentinel node uptake, Gregory says, citing the AMA's CPT Assistant, December 1999.

The provider also gets static images at intervals until he can identify the sentinel node. Then the gamma camera gets multiple images from different angles to pinpoint the node's location, Gregory says. The provider marks the sentinel node's rough location on the skin so the surgeon can easily identify it.

Relevant code: Use 78195 (Lymphatics and lymph nodes imaging) to describe the nuclear medicine imaging of the site, called lymphoscintigraphy.

The AMA says lymphoscintigraphy includes the tracer injection, [...]