Inpatient Facility Coding & Compliance Alert

Question: The pathologist examined a bursa fluid aspirate smear from the left elbow, identifying reactive synovial lining cells. He also used polarizing microscopy to diagnose uric acid crystals present. What is the correct coding for this case?

Utah Subscriber

Answer: Assuming that the pathologist examined direct smears from the bursa fluid aspirate and performed light microscopy with a polarizing lens to identify the uric acid crystals, you should code the procedure as follows:

• 88104 — Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
  
• 89060 — Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine).
  

The pathologist should not assign the diagnosis code based on the uric acid findings alone. The ordering physician will take the pathology results and the clinical presentation to assign a specific code, such as 274.9 (Gout, unspecified).

Do this: Lacking a final diagnosis, the pathologist can report the ordering diagnosis as the reason for the service.