Wiki Lymph Node Biopsy

[angieanders77@yahoo.com]

My Op note reads as bilateral pelvic lymph node biopsy was performed (documentation does support this). The specimen section also reads RT and LT Sentinel Lymph nodes.
The pathology report reads specimen searched and no lymph nodes identified.

Can the provider still bill 38570- Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple

Would the pathology report ever change the CPT code if specimen states not identified? Or would pathology only affect the code selection if it was selected and path reflected specimen was complete vs limited.

He also performed Vaginal hysterectomy 58552 and mapping 38900
Any help is appreciated

 

[csperoni]

Hmmm. Not something I've ever come across coding at least hundreds if not thousands of these types of cases. And a bit of a dilemma. The physician injected ICG dye, mapped the sentinel nodes, removed the areas that lit up and ultimately it turned out they weren't lymph nodes??
I would query the physician and ask if they want to make any amendments to their op note. Ultimately, the op note is the record of what took place.
If the situation were reversed and you had pathology of lymph nodes, but it was not in the op note, you wouldn't bill 38570 unless there was an amendment to the op note.
Might be a good scenario to reach out to ACOG or SGO for.

While not your question, I will note 58552 is laparoscopic assisted vaginal hysterectomy with BSO (which makes sense), not straight vaginal hysterectomy.

 

[Cmama12]

I agree this is unusual - maybe the mapping failed, and he didn't document it? I know I had a case a while back, and the result of my query was that if the work was supported by the op note, we should still bill it.