Wiki 38571-52 & 38570-59 Billable combination?

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tloeb

tloeb

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When a unlilateral pelvic lymphadenectomy is performed and also pelvic sentinel lymph node dissection is performed can both 38571-52 and 38570-59 be billed together? As below my provider performed the sentinel dissection and then performed a Right lymphadenctomy after frozen results:

At this time, I broke scrub and turned my attention to the console portion of the case. Round ligaments were identified and transected with monopolar cautery. Bilateral sentinel lymph nodes were identified on the left just under the external iliac vein. Right side did not trace. Perirectal and perivesical spaces were developed and ureters were well out of harm's way during the dissection. These were sent separately for permanent specimen and special microdissection IHC cytokeratin protocol.
Frozen revealed a grade 1 tumor approaching the cervix with <50% myometrial invasion on representative section, I decided to remove right pelvic nodes due to concern for possible cervical involvement.
We turned our attention to the right pelvic lymph node dissection. Right pelvic lymph node dissections were performed using the following borders - genitofemoral nerve laterally, obturator inferiorly, superior vesical artery and ureter medially, deep circumflex iliac vein caudally and the mid-portion of the common iliac vessels cephalad. Electrocautery was used for hemostasis.
 
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tloeb said:
When a unlilateral pelvic lymphadenectomy is performed and also pelvic sentinel lymph node dissection is performed can both 38571-52 and 38570-59 be billed together? As below my provider performed the sentinel dissection and then performed a Right lymphadenctomy after frozen results:

At this time, I broke scrub and turned my attention to the console portion of the case. Round ligaments were identified and transected with monopolar cautery. Bilateral sentinel lymph nodes were identified on the left just under the external iliac vein. Right side did not trace. Perirectal and perivesical spaces were developed and ureters were well out of harm's way during the dissection. These were sent separately for permanent specimen and special microdissection IHC cytokeratin protocol.
Frozen revealed a grade 1 tumor approaching the cervix with <50% myometrial invasion on representative section, I decided to remove right pelvic nodes due to concern for possible cervical involvement.
We turned our attention to the right pelvic lymph node dissection. Right pelvic lymph node dissections were performed using the following borders - genitofemoral nerve laterally, obturator inferiorly, superior vesical artery and ureter medially, deep circumflex iliac vein caudally and the mid-portion of the common iliac vessels cephalad. Electrocautery was used for hemostasis.
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I don't think there is any rationale for bypassing the edit... In other words, it's not a separate session, provider, structure, etc.. SGO's guidance is

In the event a unilateral complete pelvic lymphadenectomy was performed on one side and a contralateral sentinel node biopsy on the other, the best way to code this would be the appropriate hysterectomy code, 38570 for the biopsy and +38900...

www.sgo.org

Correct Coding When Sentinel Mapping Fails to Identify a Sentinel Node | Stephen H. Bush II, MD | Society of Gynecologic Oncology

The use of sentinel lymph node biopsy has been rapidly expanding for endometrial, cervical, and vulvar cancers. The success rates of mapping vary somewhat by disease and publication but up to 20% may fail to map at least unilaterally. OurRead More ›
www.sgo.org www.sgo.org
 
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Hello to all! :) and Thank you so much to our experts in OBGYN for sharing your knowledge with us, and providing rational, and Resources to learn from!!! I read and keep notes-so helpful! Please forgive me, but I don't understand why this article and some of you agree with it, why we don't code Unilateral pelvic lymphadenectomy that was actually done on One side? 38571-52 (for one side). I read the article 2-3 times and cannot understand why the author suggest to bill only 38570 for biopsy+38900. Thank you for your help!
""
Uterine Cancer

In the event a unilateral complete pelvic lymphadenectomy was performed on one side and a contralateral sentinel node biopsy on the other, the best way to code this would be the appropriate hysterectomy code, 38570 for the biopsy and +38900-50 for the bilateral sentinel node mapping as a bilateral complete lymphadenectomy was not performed as described in 38571. If mapping failed bilaterally then it would be appropriate to use the +38900 -50 in addition to either 38571 or 38572 depending on the extent of lymphadenectomy performed.""
 
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natashalage said:
Hello to all! :) and Thank you so much to our experts in OBGYN for sharing your knowledge with us, and providing rational, and Resources to learn from!!! I read and keep notes-so helpful! Please forgive me, but I don't understand why this article and some of you agree with it, why we don't code Unilateral pelvic lymphadenectomy that was actually done on One side? 38571-52 (for one side). I read the article 2-3 times and cannot understand why the author suggest to bill only 38570 for biopsy+38900. Thank you for your help!
""
Uterine Cancer

In the event a unilateral complete pelvic lymphadenectomy was performed on one side and a contralateral sentinel node biopsy on the other, the best way to code this would be the appropriate hysterectomy code, 38570 for the biopsy and +38900-50 for the bilateral sentinel node mapping as a bilateral complete lymphadenectomy was not performed as described in 38571. If mapping failed bilaterally then it would be appropriate to use the +38900 -50 in addition to either 38571 or 38572 depending on the extent of lymphadenectomy performed.""
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Medicare has indicated the following: : "If a code exists for the comparable unilateral procedure, report the appropriate unilateral code. If a code does not exist for the comparable unilateral procedure, report the bilateral code with modifier 52 appended. In this instance, modifiers LT or RT may be reported in another modifier position on the same claim line to describe which side the reduced procedure was performed on."

So the article was written by one of SGO's physicians and while he may have been on their coding committee, it does not always mean he has expert coding knowledge or even agrees with Medicare. You could look at 38570 to mean it is a code that could interpreted as representing a partial bilateral or unilateral procedure. That is, you take out something less than all lymph nodes (rather than the complete removal as described by 38571) and they could be taken from one or both sides, or just from one side, or all from one side and 1 from the other side. On the other hand you might consider that 38571-52-RT is the correct way to go (based on the op note for the surgery in the original question) along with 38570-59 for the biopsy on the other side. The payer will decide whether they believe that the modifier -59 applies in this case. If it does not, you would get a denial on 38570 and half payment on 38571. If they do accept coding for both, you may still get a reduced amount on both codes since they may apply a multiple procedure discount as well.

You will notice that the article does not indicate which hysterectomy code he is suggesting (and it might be a code that includes lymph node removal in which case 38570 would be added for just the sentinel biopsy), but he could also be interpreting 38570 as the correct code for the removal of anything less than complete removal if the hysterectomy code did not include any lymph node removal. And of course the bottom line is what will the payer accept? There is also one other consideration here. If the hospital is billing for this procedure using a CPT code, they cannot add a modifier -52 to the code 38571 and therefore would likely bill 38570. If you are billing 38571 instead there will not be an agreement on the codes which might result in a dispute, delayed payment or even down coding.
 
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Melanie makes a bunch of great points above. FYI - SGO typically does a pretty good job with coding advice, but that doesn't mean I've never seen clearly incorrect (or outdated) information from them. Different payors, different coders, different healthcare systems could have opposite opinions when the procedure performed is not perfectly described by existing CPT. I'll weigh in with my opinion here.
If I'm understanding correctly, there was a full pelvic lymphadenectomy (due to non mapping) on one side, and a sentinel node excision on the other. When that is the case, there is less work performed than 38571. The author is recommending 38570 since a full bilateral lymphadenectomy was not performed. I suppose 38571-52 instead of 38570 could be reasonable. However, from a revenue cycle perspective, mod -52 will most likely result in a 50% payment.
I would not object to coding 38571-52 from a coding standpoint. I would object to coding 38571-52 with 38570-59. To me, -59 would not be appropriate in this scenario.
If your opinion is that for the particular case, there is significant additional work, time or complexity, you could consider 38570-22.
For me personally, I would code (assuming TLH BSO <250gms, lap rt pelvic lymphadenectomy, lap lt lymph node sampling, ICG dye injection at 3 & 9 oclock)
58571
38570-22
38900-50
I would have loved an extra sentence making it practically audit proof connecting the dots of additional work. However, my opinion is that what is documented is just enough to use -22 for significant extra work/complexity. In my opinion, that is most likely to result in accurate payment and coding describes the procedures performed.
 
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