Coding, Classification and Reimbursement

Hospital billing - CPT 38900 vs. and/or 38792

  • 1.  Hospital billing - CPT 38900 vs. and/or 38792

    Posted 02-11-2019 11:27

    Scenario: the breast surgeon is injecting the radiactive isotope in the nuclear medicine dept. After the appropriate time frame the patient is then brought to the OR, where a lymphatic mapping injection is performed along with the primary surgical procedure(s).

    Question: 1)  Is it appropriate to charge for both CPT 38900 - Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed AND CPT 38792 - Injection procedure; radioactive tracer for identification of sentinel node?

    2) If so, what modifier would be the most appropriate?

    3) If not, which of the two codes is the most appropriate to bill?

    Thanks in advance! 

    Erin Miller
    Medical Review Analyst

  • 2.  RE: Hospital billing - CPT 38900 vs. and/or 38792

    Posted 02-12-2019 08:30
    ​NCCI edits show that 38792 is a component of 38900, but a modifier is permitted if they are truly separate.  In my opinion, "separate" would entail a separate surgery setting or contralateral breast.  When performed during same surgery on same breast, this would not meet definition of "separate" and will not  be reported.  Only report one code - I would recommend to report only 38900 when both radioactive tracer injection and mapping with non-radioactive substance is performed.  Note that 38900 is an add on code, so the parent code must also be reported.

    Sheila Goethel
    Coding Services Senior Manager