Sentinel node is the first in the chain of lymph nodes which drains lymphatic fluid from the malignant tumor. In sentinel lymph node injection the physician tries to identify the first lymph node receiving lymphatic drainage from a tumor. Sentinel lymph node injection is done commonly for breast cancer and melanoma. The injection is usually done several hours before or a day before surgical procedure to remove sentinel nodes.
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CPT code used for Sentinel Node Injection
For Sentinel Node injection CPT, we should have a proper documentation supporting injection procedure. There are few scenarios where medical coders’ gets confuse with the Lymphoscintigraphy which is an imaging procedure. There is very small difference for coding injection and imaging procedure. For coding Sentinel node injection we have a separate CPT code 38792 while for lymphoscintigraphy we have to code 78195. If the procedure is done for taking images we have code 78195 cpt code and if the exam is performed only for sentinel node injection we have code 38792.
38792– (injection procedure for identification of sentinel node)
78195– Lymphatics and lymph node imaging
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When to code 38792 & 78195
The CPT code 78195 includes both the imaging and injection of the radioactive tracer. Hence, whenever there is only injection of radioactive tracer is done we will report 38792. But, along with injection if there is imaging is done, we will report only 78195. We cannot code 38792 along with 78195, because 78195 CPT code includes 38792 and hence no modifier can also be used here. So, next time do check the report properly and code accordingly.
Sample charts for 38792 and 78195
NUCLEAR MEDICINE SENTINEL NODE INJECTION:
CLINICAL HISTORY: Right carcinoma of the breast. Radiopharmaceuticals: 526 uCi technetium 99m Lymphoseek intradermally, lateral right breast. Utilizing sterile conditions 526 uCi of technetium 99m Lymphoseek was injected intradermally in the 9 o`clock lateral aspect of the right breast posterior to the localizing wire. The intradermal injection was handled satisfactory by the patient. No complications were observed. The patient left the Breast Care Center for the OR holding area in satisfactory condition. No lymphoscintigraphy was performed.
Now, in the above report it is clearly mentioned that there was no lymphoscintigraphy was performed. The report only talks about the injection of radioactive tracer lymphoseek intradermally in the breast. There was no imaging was obtained in this report. Hence, we will report only 38792.
EXAM: NUC MED LYMPHOSCINTIGRAPHY
CLINICAL INFORMATION: Left breast cancer. DESCRIPTION: Technique: A total dose of 1.1 millicuries of 99m-technetium sulfur colloid was injected into left subareolar region. Anterior planar image were acquired.
FINDINGS: Tc99m-sulfur colloid injection was performed successfully without incident. The patient tolerated the procedure well.
IMPRESSION: Successful lymphoscintigraphy tracer injection and imaging.
Now, in this report it is clearly mention that planar images were obtained. Along with injection of sulfur colloid in the subareolar region, imaging was also done. Hence, in such reports we will code only 78195.