Basics of CPT code 38792

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. Mainly CPT code 38792 and 78195 are used for coding sentinal node injection and imaging.

According to CPT, code 38792 (injection procedure; lymphangiography for identification of sentinel node) is used to code the injection of the radioactive material and the blue dye, while the imaging component of the lymphoscintigraphy is coded 78195 (lymphatics and lymph glands imaging [for sentinal node injection, see 38792]). Each of the code descriptions specifically refers to the other, and both also indicate that the excision of the node identified should be coded 38500-38542. 

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CPT code used for Sentinel Node Injection

An injection procedure is performed for identification of a sentinel node, also referred to as lymph node mapping. Lymph ducts usually drain to one lymph node first, called the sentinel node, which is identified using a combination of weak radioactive dye (technetium-labeled sulfur colloid, technetium-99) measured by a hand-held probe, followed by injection of a blue dye (isosulfan blue) that stains the lymph tissue bright blue so it can be seen.

The radioactive dye is injected into the tumor site or tumor bed and travels from the tumor site to the sentinel node. This may take as little as 45 minutes or as much as 8 hours. The radioactive dye is followed by an injection of the blue dye. When the radioactive and blue dyes have reached the lymph nodes, a separately reportable lymph node biopsy is performed.

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 CPT 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; radioactive tracer for identification of sentinel node

78195–  Lymphatics and lymph node imaging

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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. 

Diagnostic nuclear lymphatic and lymph node imaging is a tool for studying diseases involving nodal tissue and evaluating lymphatic transport. The patient is placed in a supine position and radioactive antimony sulfide colloid is injected according to the lymph node to be visualized. For axillary and apical lymph nodes, for example, the injection is into the medial two interdigital webs of the hand and imaging is done two to four hours later.

For the internal mammary lymph nodes, the injection is into the posterior rectus sheath below the rib cage and imaging is dependent upon the study. For the iliopelvic nodes, injection is into the perianal region with the patient in a knee to chest position. A scintillation or gamma camera takes planar images of the study area on computer screen or film by detecting the gamma radiation from the radiopharmaceutical in the lymphatic tissue as it “scintillates” or gives off energy when coming in contact with the camera’s detector.

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.

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When to code CPT 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.

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HCPCS Codes linked with CPT code 38792

A4641 Radiopharmaceutical, diagnostic, not otherwise classified
A4649 Surgical supply; miscellaneous
A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries

RVU and Fees for CPT code 38792

Additional Code Information CPT code 78195

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Sample charts for 38792 and 78195

Report 1

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.

CPT: 38792

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.

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Report 2

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.

CPT: 78195

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.