Pathology/Lab Coding Alert

Parse ‘sentinel node’ terminology to get the pay you deserve.

If seeing “lymph node” in a pathology report makes you freeze with uncertainty, we have the tools for you.

Pitfall: When doubt makes you live by “better safe than sorry,” you could be leaving legitimate lymph node pay on the table — $71.98 for a missed lymph node biopsy exam, or $290.69 for a missed lymph node regional resection exam (2022 Medicare Physician Fee Schedule national facility amount, conversion factor 34.6062).

Instead: Master your lymph node coding with the following expert advice.

Distinguish 3 Lymph Node Coding Options

Sometimes you can separately bill for your pathologist’s lymph node examination in addition to another tissue specimen. When that’s the case, you have the following three coding options to choose from:

• 88305 (Level IV - Surgical pathology, gross and microscopic examination … lymph node, biopsy …)
• 88307 (Level V - Surgical pathology, gross and microscopic examination … lymph nodes, regional resection …)
• 88307 (… Sentinel lymph node …)

The primary difference between the biopsy code (88305) and the regional resection code (88307) is the surgeon’s documentation of “biopsy” versus documentation of resecting lymph nodes in a specific region. The latter typically involves named lymph node regions, such as axillary, mediastinal, periaortic, or iliac. “If the op report calls the specimen a lymph node biopsy, you shouldn’t code a resection even if the pathologist finds more than one lymph node in the submitted specimen,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Arkansas.

Sentinel: A sentinel lymph node specimen may also entail a single node, but the way the surgeon identifies the specimen and the way the pathologist processes the tissue leads to billing 88307 instead of 88305. A sentinel node is the first lymph node encountered as substances, such as cancer cells, “drain” from a lesion site.

The op report will typically document a procedure such as methylene blue drainage to identify the sentinel node. Once received, the pathologist performs a more granular exam of the sentinel node, typically processing the node in multiple blocks with serial sectioning at multiple levels, thus producing and examining a large number of slides. The pathologist will often also carry out special stains on some of the slides.

Understand Lymph Node Bundling Rules

Now that you know the three lymph node coding options, you should understand that you cannot separately bill lymph nodes in addition to many surgical specimens due to bundling rules. Knowing when you can — and can’t — separately report lymph nodes depends on mastering these bundling rules.

Bundled by instructions: When the CPT^® definition includes lymph nodes, you know you can’t report 88305 or 88307 for lymph node biopsy or resection in addition to the primary specimen. Make sure you’re familiar with the following specimens that include the lymph node exam by definition:

• 88309 (Level VI - Surgical pathology, gross and microscopic examination, … breast, mastectomy - with regional lymph nodes …)
• 88309 (… larynx, partial/total resection - with regional lymph nodes…)

Bundled by experts: Coding authorities describe a couple of additional specimens that typically include incidental lymph nodes, even though the CPT^® definition doesn’t state “with regional lymph nodes.” According to the College of American Pathologists, you should bundle associated lymph nodes with the following specimens:

• 88304 (Level III – Surgical pathology, gross and microscopic examination, … gallbladder …)
• 88307 (… colon, segmental resection, other than for tumor)
• 88309 (… colon, segmental resection for tumor)
• 88309 (... colon, total resection)

Bundled by practice standards: In addition to bundling lymph nodes from the preceding “firm” specimen list, you should also bundle lymph nodes that typically come attached to the primary surgical specimen, such as the following:

• 88307 (... liver, partial resection)
  includes attached hepatic, cystic and phrenic lymph nodes
• 88309 (… lung - total/lobe/segment resection)
  includes attached hilar and intrapulmonary nodes
• 88309 (... pancreas, total/subtotal resection)
  includes attached pancreatic and pyloric lymph nodes
• 88305 (… spleen)
  includes attached splenic lymph nodes

Exception: Sentinel lymph nodes are always separately billable, even when bundling rules prohibit a distinct code for lymph node(s) with a particular surgical specimen.

Know when to override bundles: Generally speaking, if the lymph nodes are not “associated” with the specimen, or if the surgeon individually identifies — by labeled container, mention on the requisition, or by other means — the associated lymph nodes, you can separately charge for them using the appropriate lymph code.

Check Out These Examples

Try your hand at the following examples before you read our answers.

Example 1: The pathologist examines a right breast lumpectomy specimen plus a right axillary lymph node separately identified and submitted by the surgeon. The pathologist examines slides from two blocks prepared from the lumpectomy and diagnoses ductal carcinoma in situ (DCIS). The pathologist examines one block prepared from the lymph node and diagnoses normal lymphatic tissue.

Solution 1: You should code the case as 88307 (… Breast, mastectomy - partial/simple …) and 88305 ( … lymph node, biopsy …). Although 88309 (… breast, mastectomy - with regional lymph nodes …) bundles lymph nodes with a mastectomy specimen, that code refers to a total mastectomy that includes the contiguous lymph nodes. The pathology report might describe this type of specimen using different names, such as “simple mastectomy with axillary dissection,” “modified radical mastectomy,” or “total mastectomy.” You should not list 88309 for a specimen such as a “partial mastectomy,” “lumpectomy,” “tylectomy,” “quadrantectomy,” or “segmentectomy.” Because the surgeon separately identifies and the pathologist separately diagnoses the lymph node, which is not attached to or associated with the lumpectomy specimen, you should bill the case as two distinct specimen exams.

Example 2: The pathologist receives a skin lesion specimen from the patient’s left thigh, plus two sentinel lymph nodes identified as draining from the excision site toward the inguinal lymph node region. The pathologist separately diagnoses each lymph node, processing each node in two blocks and staining serial sections from multiple levels of each block with S100 stain for melanoma.

Solution 2: You should code the skin lesion exam as 88305 (… Skin, other than cyst/tag/debridement/plastic repair …). You should additionally report each sentinel lymph node exam as 88307. For the S100 special stain, report one unit of 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) for each specimen, which is the code descriptor unit of service.