General Surgery Coding Alert

Although it may seem counterintuitive, you don't bill for sentinel node biopsies according to the number of biopsies the surgeon performs. And, to code properly you must be aware of payer guidelines that limit the use of this technique to exclude certain patients or tumors above a given size. 'Sentinel' Node Provides Early-Warning System Sentinel lymph node biopsy "is a technique that allows sampling of the lymph node or nodes that receive drainage directly from a tumor or an area of carcinoma," according to Medicare guidelines. In other words, such biopsies allow the surgeon to determine if a cancer has spread to the most likely lymphatic drainage area or if it is contained at the primary location. The advantage of this technique is that if the sentinel lymph node is negative for metastases, the surgeon need not perform a complete axillary lymphadenectomy, thereby avoiding the morbidity and complications associated with that procedure.
 
The sentinel node biopsy occurs in two steps, says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc., and chief billing officer for the University of Illinois Hospital physicians in Chicago. First, the physician must identify the sentinel node using one or a combination of separately reportable visualization procedures (See "Visualize Better Payment for Sentinel Node Biopsy Procedures," General Surgery Coding Alert, June 2003). After the surgeon has located and marked the node, he or she proceeds with the biopsy itself. CPT provides, and payers observe, several codes to describe the excision, depending on the depth and location of the node:
  38500 Biopsy or excision of lymph node(s); open, superficial
  38505 ... by needle, superficial (e.g., cervical, inguinal, axillary)
  38510 ... open, deep cervical node(s)
  38520 ... open, deep cervical node(s) with excision scalene fat pad
  38525 ... open, deep axillary node(s)
  38530 ... open, internal mammary node(s). Incisions, Not Biopsies, Determine Coding  When reporting more than one biopsy, you should keep in mind that the number of incisions not the number of biopsies determines the number of codes and/or units. That is, 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. When reporting more than one biopsy code, append modifier -59 (Distinct procedural service) to the second and subsequent codes.
 
For 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, Church says. If the surgeon performs the same procedures through different incisions, you may report 38525 and 38500, [...]