Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)

CMS National Coverage PolicyN/AArticle TextSentinel 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 GuidelinesAn 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 theydo havean ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections1862(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 provisionsotherthan 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 theyhave nothad 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 CLAIMSThe 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 patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould 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'sA4641 - TechnetiumTc-99m Human Serum AlbuminVital 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.