Wiki Sentinel lymph node with Vulvectomy 56630(56633), 56631 (56634)

[natashalage]

Hello OBGYN coders, professionals.
I am new to this specialty and there is So Much to learn. I will greatly appreciate your answer to my question. Thank you!
The question is do we code Sentinel lymph node (SNL) resection separately from Vulvectomy Or you use a combined code 56631? I will give you more details. Let's say MD is performing Radical Partial Vulvectomy- 56630. MD also did mapping 38900 and resected SNL in inguinofemoral area. Pt has no tumor per Op note and pathology. Per Path- only one SNL was submitted.
To me: we use 56631 when Deep lymph nodes are removed or MD specifically says' lymphadenectomy is performed." I would code SNL separately as 38531 along with vulvectomy 56630 and mapping 38900.
56631- Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy
38531-Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
38900-ntraoperative identification (eg, mapping) of sentinel lymph node(s)....
Here is Op note for more details:
Procedure:
1. Left inguinofemoral sentinel lymph node mapping with indocyanine green
2. Excision of left sentinel lymph node ("hot", not green)
3. Left vulvar excision to fascia
Findings:
1. Examination under anesthesia was notable for no clinically palpable nodes.
2. There was evidence of a prior scar along the left labia with millimeter amount of residual ulceration visible.
3. Lymphoscintigraphy identified a left sentinel lymph node lying medial to the femoral artery. ICG mapping failed
“….
The femoral artery was identified and a hot node was then identified at the proximal medial side of this vessel. The lymph node was tested with the lymphoscintigraphy gamma probe and was noted to have activity in the 6,000s. This lymph node was elevated with Singley forceps and dissected away from the artery and lymphatic tissue. The inferior margin of the specimen was ligated, divided, and removed. The gamma probe confirmed this to be the sentinel lymph node with detection numbers in the 6,000s. The inguinal node site was irrigated and excellent hemostasis was noted. Camper's fascia was approximated with 2-0 vicryl. The sub-dermis was re-approximated with 3-0 Vicryl. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.
We then turned our attention to the vulvar excision.
The vulva was marked with a fusiform shape with care to obtain a 1-2cm margin around the visible scar. There was no gross residual visible disease. The medial margin was modest in order to preserve the patient's clitoris. A scalpel was used to incise the dermis and epidermis and the subcutaneous fat was then dissected away from the fascia. The fusiform shaped specimen was marked and then sent to pathology for review.

Specimen(s) Received
A:Left inguinal sentinel lymph node
B:Left partial radical vulvectomy
C:Left partial radical vulvectomy, medial margin
FINAL PATHOLOGIC DIAGNOSIS
A. Left inguinal sentinel lymph node, biopsy: No tumor in one lymph node (0/1).
B. left vulva: No residual invasive squamous cell carcinoma

 

[csperoni]

From SGO Coding Q&A for vulva:

How do you code for bilateral inguinal sentinel lymph node removal performed at the time of radical vulvectomy?​

Billing depends on the dye that was injected and the procedures performed. The identification of the sentinel nodes with non-radioactive dye is reported using code 38900 (Intraoperative identification (e.g., mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed) with the 50 modifier for bilateral procedures. If the mapping is successful then use 38531 (biopsy/excision of inguinofemoral node(s) with modifier 50 if bilateral, as well as the code for complete (56633) or partial (56630) radical vulvectomy. If lymphadenectomy is required, then you can still use the mapping code (38900-50) but you should use the code that bundles radical vulvectomy with unilateral or bilateral lymphadenectomy (see codes 56631 – 56637).

It is very possible different providers/facilities perform this procedure differently, but from your op note, it appears there is also a RADIOACTIVE tracer injected as ICG failed. Your might want to look at 38792 Injection procedure; radioactive tracer for identification of sentinel node as well. If the surgeon did a lymphoscintigram, check 78195 instead of 38792 (but that would be done & billed by nuclear medicine not the surgeon around here).

 

[natashalage]

Dear Christine, Thank you very much for your response! You are always there when we need help and sharing your experience with us is greatly appreciated!
I understood the rational on vulvectomy and sentinel nodes and now got puzzled by 38792, 78195. I read the Op note and it was done. So, I will bring this to our team to discuss and confirm who is billing for it (nuclear medicine?) to make sure we are capturing all charges for reimbursement.
"......
The lesion in her left labia was injected with a total of 4mL of 1.25mg/dL ICG in four quadrants under the dermis. Massage of the wheel of dye was then performed to aid in lymphatic uptake. We then directed our attention to the left groin. The gamma probe identified activity in the primary injection site in the 20,000 range. Background of the groin was in the 200-300s. The left femoral triangle was marked and a 3 cm skin incision was made parallel to the inguinal ligament approximately 2 cm below an line marking the plane between the ASIS and the pubic tubricle in the region where the gamma probe identified activity in the 1,000s. Camper's fascia was divided and superior and inferior skin flaps were elevated with sharp dissection and ligation of superficial vessels where necessary. The femoral artery was identified and a hot node was then identified at the proximal medial side of this vessel. The lymph node was tested with the lymphoscintigraphy gamma probe and was noted to have activity in the 6,000s. This lymph node was elevated with Singley forceps and dissected away from the artery and lymphatic tissue. The inferior margin of the specimen was ligated, divided, and removed. The gamma probe confirmed this to be the sentinel lymph node with detection numbers in the 6,000s. The inguinal node site was irrigated and excellent hemostasis was noted. Camper's fascia was approximated with 2-0 vicryl. The sub-dermis was re-approximated with 3-0 Vicryl. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.

We then turned our attention to the vulvar excision. ..."