Pathology/Lab Coding Alert

Get paid when pathologists do more than 88173

Your pathologist might perform several steps to complete a fine needle aspiration (FNA) evaluation -- and you'll have to be familiar with codes from surgery (10021) to cytopathology (88172) if you want to capture full payment.

The problem: CPT provides separate codes for FNA procurement (10021-10022), specimen adequacy check (88172), specimen diagnosis (88173), and additional services such as special stains (88312), but the code definitions don't fully define when and how you can report these services for FNA.

The solution: AMA, CMS and specialty societies give direction about how to use these codes, the experts say.

1. Pathologists Can Report Surgical Code for FNA Procurement

The pathologist often receives an FNA specimen from another physician who acquired the aspirate from the patient -- but not always. Opportunity: If your pathologist aspirates the lesion to procure the FNA specimen for examination, you should report 10021 (Fine needle aspiration; without imaging guidance) for the service. "The pathologist can report this code even though it is in the surgery section of CPT," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Although CPT provides an alternative FNA procurement code, your pathology practice won't be likely to use 10022 (... with imaging guidance) because it includes imaging guidance, which radiologists, not pathologists, commonly perform.

Hidden Trap: If the patient undergoes a more extensive diagnostic surgical procedure at the same site on the same day, Medicare may not pay for the FNA. That's because the National Correct Coding Initiative (NCCI) edits bundle FNA with many biopsy procedures under the policy of "sequential procedures." This policy states that when the physician performs a second procedure because the initial procedure did not successfully accomplish a medically necessary service, you should only report the CPT code for one procedure, generally the more invasive service.

Example: The physician performs a breast lesion FNA without imaging guidance (10021). Because the FNA results are not conclusive, the physician decides to perform a percutaneous needle core biopsy of the same lesion (19100, Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]). Because NCCI bundles 10021 with 19100 as sequential procedures, Medicare would pay only for the more extensive procedure that accomplished the diagnostic goal -- 19100.

But that doesn't mean you can never report an FNA (10021) on the same day as a bundled biopsy code. "If the FNA and the biopsy involve different anatomic sites or different patient encounters, you can report both services by appending modifier -59 [Distinct procedural service]," Slagle says.

Don't Miss: Even if the surgeon performs both an FNA and a biopsy at the same site, the pathologist can still report the FNA specimen exam. "Although NCCI bundles FNA procurement with many biopsy codes, it does not bundle FNA pathology examination codes 88172 and 88173 with biopsies," Slagle says. That means you can bill for the pathologist's exam of the FNA specimen, even if you can't bill for taking the specimen. 

Tip: Medicare's fee schedule used to list a professional component and technical component fee for FNA procurement codes 10021 and 10022, but now only lists the codes as a global service. If your pathologist used to bill only for the professional component, you should realize that you no longer report the code with modifier -26 (Professional component). 

2. Capture Payment for Adequacy Check

Before the FNA examination and report, the pathologist may first check the specimen while the surgical procedure is under way to ensure that appropriate cellular material is present to make a diagnosis. You should report this service as 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]).

Sometimes the pathologist must examine multiple aspirates (that is, "passes") from the same lesion to ensure an adequate specimen. The College of American Pathologists has indicated that you can report 88172 for each pass, stating, "Immediate determination of adequacy (88172) ... [is] to be reported per aspirate requiring separate evaluation." ("Cracking the Code: Advice for CPT Dilemmas," CAP Today July 1999.)

Warning: Some practitioners believe that you should not report multiple units of 88172 for multiple passes from the same lesion. "Because the code definition says 'specimen(s),' indicating one or more aspirations, you should report 88172 once per lesion, regardless of the number of passes the physician performs before acquiring an adequate specimen," says Claire Bella, compliance auditor at United Westlabs in Santa Ana, Calif.

Although experts debate this point, reporting each separately evaluated FNA adequacy check as one unit of 88172 has been standard policy for many practices for years. "Just as the AMA prescribes separate reporting for individually identified nasal polyps or hemorrhoids even though the 88304 code definition is plural, in the same way, many pathologists report an 88172 adequacy check for each separately evaluated aspiration," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business publication company in Simpsonville, Ky. "If you have occasion to talk to an insurer about its 88172 reporting policy, be sure to get the advice in writing."

3. Don't Unbundle 88173 Slides

When the pathologist provides the definitive interpretation of slides prepared from an FNA specimen, you should report 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report).

Key: The unit of service for 88173 is the aspirate. "Whether the pathologist reviews multiple slides from an aspirate, or whether the slides are direct smears, concentrated smears, or thin layer preparation, you should report 88173 once for each aspirate the pathologist examines," Slagle says.

That means you should report only 88173 for the FNA interpretation - you shouldn't additionally report any of these other cytopathology codes:

 88104 -- Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation

 88106 -- ... filter method only with interpretation

 88107 -- ... smears and filter preparation with interpretation

 88108 -- Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique)

 88112 -- Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid-based slide preparation method), except cervical or vaginal).

Some coders have asked if they can report 88162 (Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains) with 88173 when the FNA requires over five slides. The answer is no.

"Code 88162 describes narrowly defined cell sources -- other than gynecological cells or fluids, washings or brushings. The code doesn't even describe an FNA cell source, so using 88162 to report more than five slides and/or multiple stains from an FNA would be a misuse of the code," Slagle says. Similarly, you should not report 88160 (Cytopathology, smears, any other source; screening and interpretation) with 88173.

NCCI edits enforce these coding restrictions by bundling many of the codes in the range 88104-88112 and 88160-88162 with 88173 under the mutually exclusive edit pairs. Sometimes you can report 88173 with some of the bundled cytopathology codes, however.

Example: A pathologist examines an FNA from a breast mass and also examines a bronchial brushing from the same patient on the same day. Report the bronchial brush using 88104 and the FNA using 88173 with modifier -59.