Sentinel Node Biopsy: Breast
Sentinel node biopsy is not the same as lymphadenectomy, and confusing the two could have direct effects on the accuracy of your claims.
Follow these four tips to be sure you're getting everything your practice deserves from its lymph excision procedures.
Tip 1: If Biopsy Results Lead to Subsequent Excisions, Biopsy Is Billable
When the surgeon performs a sentinel node biopsy prior to an unplanned partial mastectomy (either with or without lymphadenectomy) -- and the subsequent excisions are a result of biopsy findings -- you may report the sentinel node biopsy separately.
CMS goes on record: "Sentinel lymph node biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy without lymphadenectomy," according to guidelines set forth in Chapter 3 of the National Correct Coding Initiative Policy Manual for Medicare Services.
In simple language: You can report both sentinel lymph node biopsy and lymphadenectomy during the same session as long as:
The lymphadenectomy is unplanned at the time of the biopsy
The decision to perform lymphadenectomy (at the same or a later session) is based on the results of the biopsy.
Example: The surgeon takes a biopsy of the sentinel axillary node (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). The pathology report indicates that the malignancy has spread, so the surgeon follows up with a lymphadenectomy (for example, 38745, Axillary lymphadenectomy; complete) to remove the affected tissue.
In this case, because the biopsy led to the decision to perform the mastectomy, you may report both 38525 and 38745.
Many payers will require that you append modifier 59 (Distinct procedural service) to the appropriate biopsy code (38500-38530) to further differentiate the procedure from the follow-up lymphadenectomy. In addition, your documentation should make clear that the biopsy results provided the justification for and led to the decision to perform the subsequent excisions.
Tip 2: Don't Unbundle Biopsy With Planned Lymphadenectomy
You should not separately report sentinel node biopsy (38500-38530) and a planned lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinel node biopsy in the more extensive, same-location lymphadenectomy.
Here's what Medicare says: "Sentinel lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy]," says Triple-S's local coverage determination (LCD) (this policy is typical of other Medicare carrier guidelines).
Bottom line: If the surgeon prospectively plans to perform lymphadenectomy, you should not separately report a sentinel node biopsy. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinel nodes.
Specificity Identifies Sentinel Node Biopsy
You should consider sentinel node biopsy (38500-38530) to be a more "targeted" and less invasive procedure than lymphadenectomy (38700-38780).
The sentinel node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other site). If the sentinel lymph node is negative for metastases, the surgeon need not perform a complete lymphadenectomy (which removes a much greater volume of tissue), thereby avoiding the morbidity and complications associated with that procedure.
Keep in mind, however, that the above sequence of events would be rare. The purpose of a sentinel node biopsy is to avoid a lymphadenectomy, if possible. Therefore, surgeons generally perform lymphadenectomy only if the results of the sentinel node biopsy show malignancy.
Tip 3: Excisions, Not Incisions, Count for Sentinel Node Coding
When the surgeon performs more than one sentinel node biopsy, you should realize that the number of incisions -- not the number of biopsies -- determines the number of codes and/or units.
In other words: If the surgeon performs two biopsies through the same incision, you may report only a single code. If the surgeon takes three biopsies from two different incisions, you may report two codes, etc.
Important: When reporting more than one biopsy code, append modifier 59 (Distinct procedural service) to the second and subsequent codes.
Example: Using one incision, the surgeon biopsies a superficial node and a deep axillary node. In this case, because the surgeon accesses the node through a single incision, you may report only the more extensive (higher-paying) code -- in this case, 38525.
If the surgeon performs the same procedures through different incisions, you may report 38525 and 38500, attaching modifier 59 to the lesser (lower-valued) procedure -- here, 38500 -- to indicate a separate anatomic area.
Tip 4: Watch for Mastectomy/Lymphadenectomy Unbundle
If the surgeon performs a mastectomy and lymphadenectomy during the same session, you should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19301 and 38745 separately.
Explanation: Often, with partial mastectomy, the surgeon will perform a limited axillary lymphadenectomy to remove some lymph nodes. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.
Look out for the "staged" exception:
Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time.
In such a case, you would report the lymphadenectomy as a staged procedure using 38745 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.
Visualization Is Separate With Sentinel Excision/Biopsy
If the operating surgeon (rather than a radiologist, for instance) performs visualization prior to biopsy or excision, you can report the visualization separately.
The surgeon may use either of two methods, or a combination of both, to identify a sentinel node:
1. Direct visualization (38792, Injection procedure; radioactive tracer for identification of sentinel node): The surgeon injects the vital dye (such as isosulfan blue) shortly before surgery to stain the lymphatic vessels that drain the tumor site, thereby allowing him to identify the sentinel node.
2. Lymphoscintigraphy (78195, Lymphatics and lymph nodes imaging): This nuclear medicine procedure involves injecting a radioisotope, such as technetium-99, under the skin several hours prior to surgery. The isotope acts as a radioactive "tracer," which the physician can map with a gamma camera as it flows into the sentinel node and its lymphatic channel and can detect in the OR with a hand-held device.
AMA guidelines set forth in CPT® Assistant (December 1999, Vol. 9, Issue 12) stipulate, "The injection of radioactive tracer is included in the lymphoscintigraphy procedure  performed at the same session and is not reported separately. Therefore, it is inappropriate to report 38792 when lymphoscintigraphy is performed."
You would not report both 38792 and 78195 for the same patient during the same session because 78195 always includes 38792.
Payers may differ: Individual payers, including Medicare, may allow separate reimbursement for 38792 and 78195, however. Check your payers' local coverage determinations (LCDs) for more information.
Biopsies and Anesthesia Services
When breast cancer is suspected, the anesthesiologist may provide services associated with biopsy and staging. Beth Hibbs, CCS-P, an American Health Information Management Association certified coder in Spokane, Wash., notes that biopsies include local or intravenous sedation, and sometimes monitored anesthesia care (MAC), for certain procedures. Scott Groudine, MD, an anesthesiologist in Albany, N.Y., says that the administration of local anesthesia is usually performed by the surgeon and thus included in the global surgical fee. "Almost every Medicare carrier considers anesthesiology services unnecessary when local anesthesia is used. While an anesthesiologist may put in a local, they must also provide MAC or general anesthesia to justify the medical necessity for billing the service."
Hibbs says, "The majority of biopsies performed in our area fall under 19125 (Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion). Two additional codes also define common biopsy procedures 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 19103 ( percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance)."
For the anesthesiologist, all of the procedures noted above can be coded using the appropriate surgical and anesthesia code 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified), which carries a base value of three units plus time. Groudine warns, however, that 19102-19103 describe minimally invasive procedures that rarely require an anesthesiologist's services. "If an anesthesiologist bills for these procedures, the claim is likely to be denied. Worse yet, routine submission of anesthesia claims for these procedures may prompt local Medicare carriers to develop local medical review policies (LMRPs) which severely restrict anesthesia reimbursement for breast services."
Mary Jo Marcely, CPC, senior vice president of NAPA Services, a consulting and medical billing firm in Syracuse, N.Y., advises coders to check their LMRPs and the guidelines of other carriers when using MAC. "Many LMRPs require appending modifiers to the anesthesia code. These might include modifiers -QS (MAC service), -G8 (MAC for deep complex, complicated, or markedly invasive surgical procedure), or -G9 (MAC for patient who has history of severe cardio-pulmonary condition)."
"For more invasive procedures, such as 19101 (Biopsy of breast; open, incisional), administration of MAC or general anesthesia is the norm," Hibbs says. In this case, coders should submit claims using 19101 and 00400 (and a MAC modifier if necessary).
Lumpectomy and Mastectomy
Surgical treatments for breast cancer include lumpectomy and partial, total or radical mastectomy. CPT 2002 lists a number of codes for each of these procedures:
19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19140), open, male or female, one or more lesions
19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion
+19126 each additional lesion separately identified by a preoperative radiological marker (list separately in addition to code for primary procedure).
19160 Mastectomy, partial
19162 with axillary lymphadenectomy.
19180 Mastectomy, simple, complete
19182 Mastectomy, subcutaneous.
19200 Mastectomy, radical, including pectoral muscles, axillary lymph nodes
19220 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)
19240 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle.
Note: Code +19126 is not a primary procedure and has no corresponding anesthesia descriptor. For these procedures, the primary code is 19125. Code 19140 (Mastectomy for gynecomastia) should be used only if gynecomastia (611.1) is the diagnosis.
In Hibbs' experience, a common procedure is a partial mastectomy with axillary lymphadenectomy (19162). During surgery, the surgeon excises tissue from the breast and the lymph nodes. "For anesthesia, we code to the highest base procedure. In this scenario, a lymphatic procedure is being performed in addition to a simple breast procedure. The correct surgical code would be 19162, with an associated anesthesia code of 00404 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast). Code 00404 has a base value of five units plus time."
Hibbs provides another example for coders. "A lumpectomy (19120) was performed with a lymphangiotomy (38308, Lymphangiotomy or other operations on lymphatic channels). We would code our anesthesia session to the higher base procedure of 38308, which crosses with 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla), rather than 19120, which crosses with 00400."
Sentinel lymph node biopsy is often performed in conjunction with mastectomies (although it can be performed in a separate session). As described by HGSAdministrators, Pennsylvania's Medicare carrier, this technique allows sampling of the lymph node(s) that receive drainage from a tumor or an area of carcinoma. The sentinel node is the first node to which the dermal lymphatics around a tumor drain. If the sentinel node biopsy is negative, the patient is spared lymphadenectomy. Relevant codes for this procedure are 38500-38542 and 38792. Many of these codes were revised in 2001, so coders should check that descriptions match the procedures performed.
The sentinel nodes are often biopsied after a mastectomy is preferred. Groudine notes, "Frequently, 38525 (Biopsy or excision of lymph node[s]; open, deep axillary node[s]) is used by the surgeon for the procedure. If most of the axillary nodes are removed with the breasts, then 19162 is the appropriate surgical code. If only the sentinel node is removed, then 19120 and 38525 might be used. For the anesthesiologist, it is best to bill using the same surgical codes as the surgeon with the appropriate anesthesia code. Irrespective of which codes are used for surgery, I recommend all anesthesia for breast surgeries that involve axillary lymphatics be coded with 01610."
One of the most important things for coders to remember is to link the correct diagnosis with the CPT code. Examples include primary breast tumor (174.9) and carcinoma in situ (233.0). This is crucial when reporting procedures associated with breast cancer. Marcely states, "Coders need to indicate whether breast cancer is the primary or secondary diagnosis and whether the breast cancer has metastasized from another organ, such as the lung. ICD-9 codes should be sequenced appropriately on claims, with the primary diagnosis listed first, and any secondary diagnoses subsequently."