CPT code 38792 is used to report the injection of a radiopharmaceutical for sentinel lymph node mapping, while CPT code 78195 is used to report lymphoscintigraphy imaging of the sentinel lymph nodes. Here are some coding tips for using these codes for a sentinel injection procedure:
- Assign the injection code: CPT code 38792 is used to report the injection of a radiopharmaceutical for sentinel lymph node mapping. This code describes the injection procedure only and does not include any imaging.
- Use appropriate modifiers: Modifier -RT and -LT may be used to indicate the side on which the injection was performed if the procedure is bilateral.
- Assign the imaging code: CPT code 78195 is used to report lymphoscintigraphy imaging of the sentinel lymph nodes. This code includes the imaging procedure only and not the injection procedure.
- Assign both codes: Both codes (38792 and 78195) should be used when reporting a sentinel injection procedure, as they represent two distinct and separate services that are performed in conjunction with one another.
- Follow local guidelines: Be sure to follow any local coding guidelines or payer policies that may impact coding for sentinel injection and lymphoscintigraphy. Some payers may have specific requirements for documentation or coding of certain procedures.
- Accurate documentation: Accurate documentation is essential to support the use of both CPT codes for the sentinel injection procedure. The documentation should include details such as the specific radiopharmaceutical used, the injection site, and any intraoperative findings or complications. It should also include information about the imaging procedure, such as the type of imaging performed and any abnormalities detected.