Pathology/Lab Coding Alert

Find out whether you can report these procedures together.

Your pathologist’s exam of cases involving fine needle aspiration (FNA) and/or percutaneous needle biopsy (PNB) can produce a coder’s nightmare of questions about specimen type, bundled services, and more.

Let’s look at one specific pancreas case to elucidate four rules that you can apply to other cases to make sure you get your FNA/PNB coding right — every time.

The case: The clinician (such as a radiologist or surgeon) performs an endoscopic ultrasound (EUS) and FNA on a pancreas lesion, and the pathologist consults during surgery, reporting to the clinician that the specimen does not contain cellular material adequate for diagnosis. Based on the pathologist’s consult, the clinician performs a second FNA pass, and the pathologist consults again, determining that the specimen is not adequate. Based on that report, the clinician switches to a 25 gauge needle and extracts a PNB specimen. The pathologist then processes the PNB specimen, expelling the contents onto glass slides. The pathologist removes a 35 mm visible core slide and processes it in formalin for histopathology. The pathologist then smears one slide and examines it, reporting to the clinician that the specimen is adequate, then cytolyt to the remaining fluid on and processes it for cytologic evaluation.

Terminology tip: An FNA uses a fine needle to extract an “aspirate,” which is fluid containing primarily cellular material and perhaps bits of tissue. A PNB uses a needle to extract a core of tissue, but the specimen may also include some fluid. “A percutaneous needle is significantly larger than a fine needle,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey.

Rule 1: Base Coding on Surgical Procedure

Cases that involve FNA and/or PNB can be very confusing because the specimens may look similar and be processed in a similar way, but the codes are different.

“To bill these cases, you need to know what the surgical procedure was, because that defines the specimen type and the coding” declares says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

If the clinician performs an FNA, you should choose the proper code(s) from the following list for the pathologist’s exam:

• 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site)
• 88173 (… interpretation and report) This code encompasses any type of slide preparation used for examination, such as liquid based or cytospin or DiffQuick stained, and you should not report an additional code for those preparations for most payers.
• +88177 (… immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure))
• If the pathologist makes a cell block, 88305 (Level IV - Surgical pathology, gross and microscopic examination … cell block, any source …)

On the other hand, if the clinician performs a PNB, you should look to the appropriate code(s) from the following list for the pathologist’s work:

• Surgical pathology biopsy code based on tissue type, such as: 88307 (Level V - Surgical pathology, gross and microscopic examination … Pancreas, biopsy ….)
• Intraoperative cytology: 88333 (Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site), +88334 (…each additional site (List separately in addition to code for primary procedure))
• Cytology exam: non- gynecological cytopathology code based on lab method such as 88112 (Cytopathology, selective cellular enhancement technique with interpre­tation (eg, liquid based slide preparation method), except cervical or vaginal)

Rule 2: Specimen Type Defines Intraoperative Consult Codes

For both FNA and PNB procedures, the clinician may request an intraoperative consultation from the pathologist to ensure that the specimen is adequate for diagnosis. To bill these consultation codes, the pathologist must have a request from the clinician and must report the findings back to the clinician during the procedure so that the clinician can decide whether to extract another specimen.

During the intraoperative consultation, the pathologist will look at slide(s) prepared by creating a thin layer of the fluid on a slide and/or touching tissue to a slide.

Key: Because the specimen processing descriptions may appear similar whether the specimen is an FNA or a PNB, you must choose the consultation code based on the defined surgical procedure, not based on whether the slide is fluid or touch from tissue.

Do this: For an FNA procedure, code the intraoperative consultation as 88172 if for the first time the pathologist evaluates slide(s) from the surgery, and +88177 for any subsequent evaluations from the same site while the patient is still in surgery. For a PNB procedure, report 88333 for any slides examined during surgery for the same site. Unlike +88177, code +88334 is only for slide consult from a different surgical site on the same day.

Rule 3: Look for Extra Procedures

In addition to the primary exam for FNA (88173) or PNB (biopsy code, such as 88307 for pancreas), the report might describe additional preparation and examination that you need to code.

For instance: Upon receiving an FNA specimen, the pathologist might pull off fluid containing a tiny bit of tissue and process it in a preservative such as formalin or CytoRich to subsequently prepare a paraffin cell block for examination. That process requires an additional 88305 for the cell block for the case.

Similarly, the pathologist might separate fluid that comes with the tissue core from a PNB procedure and place the fluid in a preservative such as Cytolyt for subsequent cytology exam using a procedure such thin layer preparation. That process requires a cytology code such as 88112 in addition to the PNB exam code.

Rule 4: Watch for Edits

Medicare’s National Correct Coding Initiative (NCCI) has something to say about reporting cases that involve pathology exam of both FNA and PNB specimens.

Myth: First, let’s dispel the myth that you can’t report together a PNB tissue exam (such as 88305) with an FNA exam (88173) because the procedures are not “medically necessary” for the same lesion. It is true that Medicare states in the NCCI Manual that a biopsy is not necessary in addition to an FNA, and that if a biopsy follows an inadequate FNA you should report just one procedure. But those rules apply to the surgical procedure, and many payers disagree that the two procedures aren’t medically necessary together. Pathology coders should report the procedures that the pathologist performs, including both histopathology and cytology from the same lesion.

That said, NCCI does hold some edit pairs that you’ll need to navigate. For instance, NCCI lists 88172 as a column 2 code with 88333, but your pathologist may perform both intraoperative consults in combination FNA PNB case. Because they are distinct specimens from different procedures, you may override the edit pair with modifier 59 (Distinct procedural service) or XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service), when appropriate.

Code the Case

After studying the preceding four rules, you should be able to code the case laid out at the start of this article. Give it a try, then look at the following coding to check your work:

• For the FNA — 88172 and +88177 for two intraoperative consults from the same lesion. Because the clinician does not ever get an adequate FNA for examination, don’t report 88173 in this case.
• For the PNB intraoperative consult on a slide to report adequate specimen - 88333
• For later histopathology exam of formalin fixed pancreas biopsy tissue, 88307
• For later cytology exam, list the appropriate code based on the lab method, such as 88112.