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Posted By Gracie Ermitano on 03-04-2018, 03:39:59 in Ob-Gyn
Hi Melanie, another question for you which I commonly encounter with my OBGYN providers being the assistant surgeon to other providers outside of their group. These are submission of CPT codes that do not match my evaluation. An example i recently encountered was a submission of a 58573 and 38572 codes provided by the primary where upon review of the report it should come up as 58570 and 38571. the reason for the mismatch was that the uterus weighs 152.8 g with no ovaries and/or tubes removed and that i selected 38571 as there were no paraaortic nodes removed. It was stated as pelvic lymph nodes (Rt and left external iliac and superior vesical arteries) and confirmed from the path specimen and gross description. I have addressed this issue with the corresponding manager(s) involved handling the accounts that the assistant should discussed it with primary for correct submission of the codes and that we are in compliant with the rules. It always turned out to be- follow what primary has selected/submitted. I am not sure of what are the specific policy and procedures concerning this situation. What can you advise or recommend? The only way i could protect myself is to educate and provide the rationale for what I came up for and make sure that I have a copy on file for the communication and whatever their decision would be. Another question Firefly imaging sentinel node identification. Should this be under the radiology, the sentinel node injection and interpretation for results? The only statement i see from the dictation was using a firefly imaging mode, the nodes were identified and then removed; these were the nodes i mentioned above. I don't think the surgeon performed the sentinel node injection procedure and i don't have any information as to the interpretation of the results for the sentinel node biopsy procedure. I appreciate your advise and feedback. Thanks you very much. Very respectfully, Gracie
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Posted By Melanie Witt on 03-10-2018, 15:46:41
SGO published an article on this topic in 2016 which I have copied below with regard to using Firefly mapping. Note that you would have to report this with 38900 which may be problematic.

Sentinel node mapping: How would you code?
You have incorporated sentinel node mapping at the time of robotic hysterectomy into your practice. You perform cervical injection of ICG, then perform laparoscopy, identify and laparoscopically excise the sentinel nodes. How would you code?

Coding for sentinel nodes for endometrial carcinoma can be a challenge. There are two components to the procedure:

Excision of the node(s). This is straightforward: 38570 for laparoscopic excision of single or multiple retroperitoneal nodes.
Intraoperative identification of the sentinel node(s), which includes injection of non-radioactive dye. The injection must be performed by the surgeon so be sure to dictate it in your op note.
There is no code specifically for intraoperative identification of pelvic/paraaortic sentinel nodes. One option is to use code +38900. This is an add-on code as designated by a “+” preceding the CPT code. Each add-on code description includes a list of codes to be used in conjunction with the specific code. Add-on codes are reimbursed at their full value, without the usual reduction applied for multiple procedures. +38900 was developed for use in breast cancer and the associated codes are for node biopsies or dissections in the chest/neck/axillary regions. Some carriers will deny +38900 when billed with 38570.

If your carrier will not recognize 38900 in conjunction with a laparoscopic retroperitoneal node dissection then you will need to use an alternate method of billing. This seems like a daunting task but for such a common procedure it is definitely worth the time and effort!

Start by using code 38999 (unlisted procedure, hemic or lymphatic system). When you use an unlisted code you need to provide the carrier with a cover letter referencing an existing code and comparing that code with the surgery you performed. For example:

Since a code for retroperitoneal sentinel node mapping is not in place, 38999 (Unlisted procedure, hemic or lymphatic system) has been used in this case to address the intraoperative identification (mapping) of sentinel nodes in this patient with endometrial carcinoma (C54.2). The procedure performed is best compared with +38900: intraoperative identification (e.g., mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed. +38900 is an add-on code for patients undergoing sentinel node mapping associated with lymph node sampling for breast cancer and melanoma. A similar code for endometrial carcinoma does not exist at the present time, therefore 38999 is being used. Sentinel node mapping is more complex when performed for endometrial carcinoma due to the location of the injection (deep cervix vs superficial sites on skin/breast) and the location of the nodes (retroperitoneal vs. axillary or inguinal). We would estimate that there is a 50 percent increase in the time and risk for the procedure performed relative to +38900.

It is helpful to include an introductory paragraph describing use of sentinel nodes for endometrial cancer with references including the NCCN guidelines. Keep summaries short and straightforward. Your biller will need to attach your letter along with your op note each time these codes are used.

Submitted by Mary J. Cunningham, MD, Upstate Medical University, Syracuse, NY

But also keep in mind the add-on code 38900 does not pair with any of the hysterectomy or lymph node codes so you may have to appeal. But in any case, one of your issues is lack of documentation to indicate what was really performed so this has to be addressed with physician education.

As to the assistant and primary surgeon codes not matching. You are responsible for coding your physician's claims based on the documentation. If the other practice is not coding correctly, you need to educate them. If they choose to ignore you, document all your conversations, send in the correct claim to the payer and also include an explanation as to why your codes are correct. Let the primary surgeon's practice know you will be doing this. Also let your physician know that the primary surgeon's office is not coding correctly. As coders we have an obligation to be ethical as well as accurate and it is never ethical, in my opinion, to allow incorrect coding to pass silently on.
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