Billing and Coding: Sentinel Lymph Node Biopsy  Medical Policy Article

Sentinel lymph node biopsy involves the identification, removal, and
evaluation of lymph nodes that drain the area of a malignant tumor. One or
more lymphatic channels or basins, each of which has its own sentinel node,
may drain any primary tumor site. When a sentinel node in a given chain is
free of tumor cells, it may be assumed that the remainder of the lymph nodes
in that lymphatic channel is also free of cancer. When tumor cells are
identified in a sentinel node, it suggests that cancer has spread to other
nodes, indicating that a regional lymph node dissection may be necessary to
assess the extent of metastasis.  
  
Methods used to identify sentinel node include use of lymphoscintigraphy
and/or direct visualization during surgery following an injection of vital dye
(e.g., isosulfan blue). Lymphoscintigraphy is a nuclear medicine procedure
performed prior to the surgical procedure to locate the sentinel node (s) for
the surgeon. It is performed by injecting a radioactive tracer under the skin,
which flows toward and into the sentinel node and its lymphatic channel and
may be imaged by a gamma camera that produces a map of the path of the
radioactive tracer and its first appearance in the sentinel node. This is
injected several hours before surgery. A Gamma probe is used during surgery to
locate the area of the sentinel node. A vital dye may be used during surgery
to visualize the lymphatic channels, allowing more effective use of the gamma
probe. Thus these techniques are complimentary.  
  
The vital dye is selectively taken up by the lymphatic vessels that drain the
tumor site and stains them blue. Multiple injections are usually made at
equidistant points around the primary lesion shortly before surgery. If a
radioactive tracer has not been injected and a gamma probe is not used, the
dissection will begin along the blue-stained vessels that are closest to the
primary dye injection site. When radioactive tracer has been injected pre-
operatively, the surgeon may use a portable, hand-held gamma-ray detection
instrument to aid in identification and confirmation of a sentinel node. When
held to the sentinel node, the level of radioactivity registers at very high
levels. (This process, called intraoperative lymphoscintigraphy, is included
in the biopsy procedure and is not reported separately). Once located, the
sentinel node is removed and sent to the pathology department for appropriate
microscopic evaluation.  
  
Sentinel node biopsy can provide accurate staging information that can be used
to determine and refine treatment options. It may also identify the presence
of metastasis. An additional advantage of sentinel node biopsy is that if the
sentinel node(s) is negative for tumor, a complete lymphadenectomy, with its
increased morbidity, may be avoided.  
  
 **Coding Guidelines:  
  
General Guidelines for claims submitted to Part A or Part B MAC:**  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.  
  
The sentinel node excision is reported using the appropriate code from among
CPT codes 38500, 38510, 38525 and 38530, and may be billed only with NOS of
001 regardless of the number of nodes excised.  
  
_Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines_  
  
An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
_Medicare Claims Processing Manual_ , Chapter 30, for complete instructions.  
  
Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.  
  
The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary, and they **do have** an ABN signed by the
beneficiary on file. Modifier GA applies only when services will be denied
under reasonable and necessary provisions, sections _1862(a)(1), 1862(a)(9),
1879(e), or 1879(g)_ of the Social Security Act. Effective April 1, 2010, Part
A MAC systems will automatically deny services billed with modifier GA. An
ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that
he/she accepts responsibility for payment. The -GA modifier may also be used
on assigned claims when a patient refuses to sign the ABN and the latter is
properly witnessed. For claims submitted to the Part A MAC, occurrence code 32
and the date of the ABN is required.  
  
Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions _other_ than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
FI and Part A MAC systems will automatically deny the services.  
  
The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they **have not** had an ABN signed by the
beneficiary.  
  
If the service is statutorily non-covered, or without a benefit category,
submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not
required for these denials, and the limitation of liability does not apply for
beneficiaries. Services with modifier GY will automatically deny.  
  
 **For claims submitted to the Part B MAC:**  
  
Claims for sentinel lymph node biopsy services are payable under Medicare Part
B in the following places of service:  
CPT codes 38500, 38510, 38525 and 38530 are payable in the following places of
service: inpatient hospital (21), outpatient hospital (22) and ambulatory
surgical center (24).  
  
CPT codes 38792, 38900 and 78195 (26) are payable in the following places of
service: office (11), inpatient hospital (21), outpatient hospital (22),
ambulatory surgical center (24) and independent clinic (49).  
  
CPT code 78195 (global/TC) is payable in the office (11) and independent
clinic (49).  
  
Lymphoscintigraphy should be coded as CPT code 78195 and reported separately
when performed prior to the surgical procedure. The injection of the
radioactive tracer, when performed by the same provider, is included in the
CPT code 78195 and should not be billed separately.  
  
CPT code 38792 can be billed for both the injection of radioactive tracer when
performed without lymphoscintigraphy; and for the injection of vital dye
(Isosulfan Blue Dye or a similar product) to visualize the sentinel node, by
the surgeon/physician who performs the injection.  
  
The NOS for CPT code 38792 may only be reported with units of one (001), for
each use, regardless of the number of injections for each substance.  
  
If one physician is billing for the injection of the tracer and the injection
of the dye, CPT code 38792 should be billed on 2 lines of coding, using
modifier 59 on the second line.  
  
Scintigraphy performed intraoperatively using a hand-held device is not
separately reimbursable, and is included in the fee for the surgical
procedure.  
  
If the sentinel node is not identified at the time of surgery or is found to
be positive for metastatic carcinoma, and additional lymphadenectomy is
performed, then the CPT codes appropriate for the location and extent of
lymphadenectomy should be used. The injection and scintigraphy codes may still
be billed, regardless of the results.  
  
**For claims submitted to the Part A MAC:**  
  
HOSPITAL INPATIENT CLAIMS:  
  

  * The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. _The principal diagnosis is the condition established after study to be chiefly responsible for this admission.  
_

  * The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  * For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-08, _Medicare Program Integrity Manual,_ Chapter 25, Section 75 for additional instructions.)

  
HOSPITAL OUTPATIENT CLAIMS

  * _The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67._ If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider _should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9)._
  * The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.

When lymphoscintigraphy is performed in the radiology department prior to
surgery to locate the sentinel node(s), lymphoscintigraphy procedures should
be coded and reported separately as a radiology procedure under the
appropriate revenue code.  
  
When injection of radioactive tracer is performed without lymphoscintigraphy,
CPT code 38792 should be used for the injection procedure under the
appropriate revenue code.  
  
The injection of the radioactive tracer should be billed with units or number
of services (NOS) of 001 regardless of the number of injections around the
lesion.  
  
When performed in the operating room, the injection of vital dye (Isosulfan
Blue Dye or a similar product) to visualize the sentinel node is not reported
as a separate operative procedure.  
  
Scintigraphy performed intraoperatively "using a hand-held device" is not
separately billable.  
  
If the sentinel node is not identified at the time of surgery or is found to
be positive for metastatic carcinoma, and additional lymphadenectomy is
performed, then the CPT codes appropriate for the location and extent of
lymphadenectomy should be used.  
  
If the surgery necessitating the lymphoscintigraphy is limited to inpatients
only, then it is anticipated that the lymphoscintigraphy and related
radiopharmaceutical will be either provided during the inpatient stay or
bundled into the inpatient DRG payment.  
  
The radiopharmaceutical tracer is billed as a drug with a revenue code
appropriate to the place of administration. Radiopharmaceuticals commonly used
for lymphoscintigraphy:

  * A9541 - Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to 20 mCi's
  * A4641 - TechnetiumTc-99m Human Serum Albumin

Vital Dye is billed as part of the surgical supplies. In the case of inpatient
claims it is bundled into the DRG payment. In the case of outpatient claims it
is part of the APC payment for the specific surgery.