Coding Corner: Coding for Radical Hysterectomy with Sentinel Lymph Node Mapping in Cervical Cancer | Sarah Kim, MD, MSCE

Sarah Kim, MD, MSCE

Several large studies have linked minimally invasive radical hysterectomy with a higher risk of cancer progression and death in women with early-stage cervical cancer. Our surgical paradigm in cervical cancer treatment is therefore transitioning from minimally invasive to open radical hysterectomy. In addition, the sentinel node detection rate, sensitivity, and negative predictive value are reported to be high in women with early-stage cervical cancer. Thus, sentinel lymph node mapping is performed more widely and replacing staging pelvic lymphadenectomy.

CPT code 58210 (30.91 wRVU) is used for radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tubes(s), with or without removal of ovary(s) for cervical cancer. If you have omitted part of the procedure, such as performing a sentinel lymph node mapping and biopsy of the lymph node rather than a full lymphadenectomy, then you have not met all the components to fulfill a 58210 code, and a -52 modifier should be added to report reduced services.

When modifier -52 is added to indicate reduced service, you should document what was different about the procedure and approximately what percentage of the usual work was completed and/or not done. Reimbursement is reduced by 25-50% (wRVU 17.38-23.18), so it is beneficial to avoid the -52 modifier if possible. It is prudent to document complexity of procedure to minimize the reduction in payment.

CPT 38900-50 describes intraoperative injection of dye for sentinel node identification. Modifier -50 is used for bilateral injections, and increases reimbursement by 150%, increasing the wRVU from 3.75 to 5.625.

CPT 58825 (wRVU 5.98) for ovarian transposition with -51 modifier indicates multiple procedures were performed at the same session but also reduces the reimbursement by 50% to 2.99 wRVU.

An alternative would be to bill for total hysterectomy without a reduced-service modifier (58150, wRVU 17.31) and a pelvic lymph node sampling (38562-51, 50% of wRVU 11.06 and therefore wRVU 5.53) and injection of dye (38900-50, wRVU 5.625). CPT 38562 describes limited lymphadenectomy for staging pelvic and para-aortic in open procedure. This would be appropriate for a situation in which only a few selected nodes were removed like sentinel lymph nodes without performing a full lymphadenectomy. This alterative may result in better reimbursement overall and save you from appeals and delays.

“Node dissection” and “lymphadenectomy” are often used interchangeably and mean that the entire nodal bundles are removed rather than a few isolated nodes. Remember not to unbundle; if nodes are removed at the time of open hysterectomy they will be coded together.

The following apply when the node procedures are not already bundled into the code. For open procedures, options are:

· 38562 – Limited lymphadenectomy for staging; pelvic and para-aortic. This would be appropriate for a situation in which only a few selected nodes were removed without performing a full lymphadenectomy. i.e., sentinel lymph node(s) or isolated enlarged lymph nodes.

· 38770- Pelvic lymphadenectomy including external iliac and obturator nodes. If bilateral use modifier 50.

· 38780- Retroperitoneal lymphadenectomy, extensive. Includes pelvic and paraaortic and infrarenal nodes.

The following codes are used in the scenario of aborted radical hysterectomy (for example due to incidental parametrial disease during laparotomy), a pelvic and para-aortic lymphadenectomy, bilateral ovarian transposition, and bilateral cervical Indocyanine green injection.

· 38780-50 (wRVU 17.7) describes pelvic lymphadenectomy including external iliac and obturator nodes (modifier -50 used for bilateral).

· 38900-50 (wRVU 3.785) describes bilateral injection of cervix for sentinel lymph node identification

· 58825-51 (wRVU 5.89) for ovarian transposition.

Sarah Kim, MD, MSCE, is a Gynecologic Oncologist at the University of Pennsylvania in Philadelphia, PA.