December 26, 2013
The surgeon documented that she performed a partial mastectomy, sentinel node mapping, sentinel node biopsy and a complete lymphadenectomy. Our question is directed at the sentinel node biopsy only as we are receiving denials for this procedure. We are reporting CPT code 38525 with 19302 and are receiving a denial as inclusive. We are not sure what modifier to use as the modifier 59 submitted on appeal is not bypassing our payor’s edit.
This is an often asked question. While the sentinel node biopsy is separately reportable with a partial mastectomy, the work is considered inclusive to the lymphadenectomy performed on the same day and is not separately reportable. The denial as inclusive to CPT code 19302 is correct. Perform a write off on the account for CPT code 38792 as a coding error adjustment for tracking purposes. Use this example as part of your compliance review.