Radiology Coding Challenge: Why is Medicare Denying a 38792, 78195 Claim

January 10, 2010

Tip: Discover true meaning of 38792 note

Question: The physician performed a sentinel node injection with lymphoscintigraphy. A note with 38792 states to report 78195 for imaging. So why did Medicare deny a claim that included both codes?

Answer: You should report 78195 (Lymphatic and lymph nodes imaging) for this service and leave 38792 (Injection procedure; for identification of sentinel node) off the claim. The Correct Coding Initiative (CCI) edits consider 38792 and 78195 to be mutually exclusive.

Helpful: CPT Assistant (December 1999) explains that imaging code 78195 includes the injection: “The injection of radioactive tracer is included in the lymphoscintigraphy procedure performed at the same session and is not reported separately. Therefore, it is inappropriate to report 38792 when lymphoscintigraphy is performed.”

Clarify the note: CPT’s note with 38792 does state, “For nuclear medicine lymphatics and lymph gland imaging, use 78195.” You may want to add your own reminder that the instruction means to use 78195 to report both injection and imaging. It does not mean to report 78195 in addition to 38792.

A separate note with 78195 states, “For sentinel node identification without scintigraphy imaging, use 38792.” Translate this note to mean that if the physician performs the injection procedure and does not perform scintigraphy, the correct code is 38792.

Keep in mind: If the physician uses a hand-held gamma detector to locate the node, this is not the same as scintigraphy, so you should report 38792. Scintigraphy involves using a gamma camera for real-time imaging of the tracer’s flow through the lymphatics. The physician uses static images taken at intervals to identify the sentinel node. He then uses multiple images from different directions to identify the exact position, according to CPT Assistant.

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