Pathology/Lab Coding Alert

Capture each 'evaluation episode' for FNA adequacy check

Per "pass" or per lesion -- how should you report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s])? The answer today depends on the payer: per lesion/anatomic site for Medicare, but per "pass" for most other payers.

Change ahead: CPT 2011 revises 88172 and adds a new fine needle aspiration (FNA) code -- two changes that will hopefully standardize your FNA coding once and for all.

Per Evaluation Episode' is the New Normal

Here are the CPT 2011 changes that impact FNA adequacy check coding:

• 88172 (revised) -- Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) for diagnosis, first evaluation episode, each site [strike through is deleted text, bold is added text]
• 88177 (new) -- ... immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure).

Note that 88177 appears directly following 88173 with a # symbol to indicate that the code is out of numerical sequence.

These code changes should streamline the following current dichotomy that you face when reporting FNA adequacy checks:

Obstacle: Coding convention, supported by the College of American Pathologists ("When and how to use CPT code 88172," CAP Today, Sep. 2006), directs you to report 88172 per "aspirate" or "pass" (fluid withdrawn from one needle insertion). But CMS (NCCI Policy Manual version 15.3, Oct. 2009) established the policy that the unit of service for 88172 is "the separately identifiable lesion (tumor)." That left coders with a twotier system for reporting 88172.

Solution: "CPT 2011 makes it clear -- you should report 88172 for the first evaluation episode (pass), and one unit of 88177 for each additional pass from the same site," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Exception: "Sometimes the pathologist evaluates two or more passes all at once; in that case the 'evaluation episode' would consist of multiple passes, and you would list only 88172," explains Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla. "But that's consistent with past coding convention for FNA adequacy check, which allows billing only when the outcome of the slide review could impact the need for a subsequent FNA."

New text notes in CPT 2011, such as the following, confirm the meaning of "evaluation episode":

"The evaluation episode represents a complete set of cytologic material submitted for evaluation and is independent of the number of needle passes or slides prepared. A separate evaluation episode occurs if the proceduralist provider obtains additional material from the same site, based on the prior immediate adequacy assessment ..."

'Adequacy Check' Standards Remain

Some things haven't changed with the CPT 2011 revisions. Keep these requirements in mind when you're reporting 88172 and 88177:

• An adequacy check involves evaluating whether the quality and quantity of the FNA aspirate is "good enough" to use for diagnostic purposes. It doesn't require providing a diagnosis.
• "The patient must still be on the 'table' ready to be 'stuck' again if the material already aspirated doesn't support a definitive diagnosis," Padget says. "To be'medically necessary,' an immediate adequacy check must be able to affect the course of the current session," he explains.

Hold Your Applause For the Medicare Fee Schedule

CPT's 88172 revision and 88177 addition appear to short circuit the current Medicare policy that allows only one unit of 88172 per site. The 2011 proposed Medicare physician fee schedule confirms the change -- you'll find Relative Value Units (RVUs) for both 88172 and 88177 for 2011. That means you can bill both codes to Medicare, when appropriate.

"At least CMS did not declare 88177 invalid for Medicare billing and maintain the current policy limiting all 'adequacy check' work to only one unit of 88172 per lesion or anatomic site," says Padget.

Caveat: The change doesn't necessarily mean you'll make much more money when your pathologist performs adequacy checks from multiple FNA passes from a single lesion. Because the 2011 fee schedule reduces the 88172 RVUs, lists 88177 with even lower RVUs than 88172, and substantially lowers the conversion factor, you shouldn't expect much more pay.

Take the following examples of three FNA passes to see what pay you could expect (based on 2010 or 2011 national nonfacility total RVUs and conversion factors):

2010 non-Medicare, report 88172 x 3:

1.44 RVUs x 3 = 4.32 RVUs x 36.8729 = $ 159.29

2010 Medicare, report 88172:

1.44 RVUs x 36.8729 = $53.10

2011 (all payers), report 88172 + 88177 x 2:

1.38 RVUs + (0.82 RVUs x 2) = 3.02 RVUs x 25.5217 = $77.08