Pathology/Lab Coding Alert

Beware ‘pass’ terminology.

With multiple specimens and procedures in a single fine needle aspiration (FNA) case, you have a chance to get paid for several services — or a chance to miss some pay your pathologist deserves.

Study the following thyroid case, then look at our experts’ coding to make sure you seize the opportunities, avoid the pitfalls, and learn how to strengthen documentation to support your coding choices.

Examine the Pathology Report

Clinical history: Palpable thyroid nodule, right lobe.

Procedure: April 23, 2013, FNA with ultrasound guidance. FNA immediate studies for specimen adequacy determination, and FNA diagnosis.

Specimen A: FNA, palpable 2 cm nodule right thyroid lobe.
First FNA pass with immediate study adequacy check — insufficient cells
Second FNA pass with immediate study adequacy check — adequate for evaluation.
Seven ThinPrep slides
Cytokeratin-19 and Galectin-3 immunostain two slides
Cytology cell block evaluation
Findings: Specimen consists of branching papillae with fiborvascular cores, and nuclei with optically clear chromatin (Orphan-Annie nuclei), consistent with papillary thyroid carcinoma

Specimen B: FNA, 1 cm thyroid isthmus nodule identified on ultrasound.
First pass immediate study, adequate for diagnosis
Four ThinPrep slides
Findings: Specimen consists of benign-appearing follicular cells, watery colloid, and macrophages. The findings are consistent with benign follicular nodule.

Capture Surgical Procedure

If your pathologist performs the FNA extraction as the pathology report in this case indicates, you can code the service using the appropriate surgical code. For an FNA with ultrasound guidance described in the pathology report, you should code 10022 (Fine needle aspiration; with imaging guidance).

Watch units: “Because the pathologist aspirated two separate lesions, you can report 10022 x 2,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

According to Medicare’s Correct Coding Initiative (CCI) Policy Manual, “The unit of service for fine needle aspiration (CPT^® codes 10021 and 10022) is the separately identifiable lesion. If a physician performs multiple “passes” into the same lesion to obtain multiple specimens, only one unit of service may be reported. However, a separate unit of service may be reported for separate aspiration(s) of a distinct separately identifiable lesion.”

Don’t miss ultrasound: For the ultrasonic guidance for FNA, you should bill 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).

For Medicare, bill just one unit of 76942 for this case, based on CCI Policy Manual instruction which states: “The unit of service for [76942] is the patient encounter, not number of lesions [or] number of aspirations …” That CCI instruction varies from CPT Assistant^® April 2005, which states, “From a CPT^® coding perspective, code 76942 should be reported per distinct lesion that requires separate needle placement.”

Do this: Check with payer rules to make sure you report the proper 76942 units.

Code Separate ‘Evaluation Episodes’

The pathology report documents three FNA “passes” with adequacy check: two for specimen A and one for specimen B. CPT^® provides the following two codes for FNA adequacy check:

• 88172 — Cytopathology, evaluation of FNA; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
• +88177 — ... each separate additional evaluation episode, same site (List separately in addition to code for primary procedure).

Forget ‘pass’: An FNA “pass” refers to a single withdrawal of fluid from a lesion through the fine needle. But the unit of service for codes 88172 and +88177 is the “evaluation episode,” which isn’t the same thing as a pass.

An evaluation episode involves the pathologist’s exam and report regarding the adequacy for diagnosis of a set of cytologic material, regardless of the number of passes performed to extract the material. Although the above pathology report refers to “pass,” the pathologist treats each pass as an evaluation episode in this case, dictating results of three immediate evaluation episodes for specimen adequacy.

Per lesion: Report 88172 for the first FNA evaluation episode adequacy check from each distinct lesion. In this case, that means 88172 x 2 (one for specimen A, and one for specimen B).

Because the pathology report documents a second adequacy evaluation episode for specimen A, the proper code for the service is +88177.

Bill FNA Interpretation

CPT^® provides one code for FNA interpretation — 88173 (… interpretation and report).

Report one unit of 88173 for each specimen — that is, all FNA material from each distinct lesion or site that is sampled. In this case, you’ll report 88173 x 2 for the right thyroid FNA evaluation and the thyroid isthmus FNA evaluation.

Learn the ‘Ancillary’ Service Rules

The pathology report for this case documents “seven ThinPrep slides” for specimen A and “four ThinPrep slides” for specimen B. Does that mean you should report 11 units of 88112 (Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal)?

No. The way the lab prepares the specimen doesn’t impact the coding — whether you receive a vial of fluid, air-dried slides, ThinPrep slides, or a combination, you should report 88173 for the pathologist’s interpretation of material from a fine needle aspiration specimen.

“You shouldn’t additionally report other cytology preparation methods, such as 88112, with FNA,” says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Say yes to IHC: Because the pathology report documents two immunohistochemistry (IHC) stains for FNA specimen A (Cytokeratin-19 and Galectin-3), you should bill two units of 88342 (Immunohistochemistry [including tissue immunoperoxidase], each antibody). Make sure you bill IHC per antibody stain, not per slide.

Don’t forget cell block: Because the pathologist processes and evaluates the remaining FNA fluid from specimen A as a cell block, you should report 88305 (Level IV - Surgical pathology, gross and microscopic examination, Cell block, any source).

Close the Case With This Code Roundup

Gather up all the codes discussed for these two FNA specimens in this thyroid case, and here’s what you have:

• 10022 x 2 for FNA extraction of two distinct thyroid nodules
• 76942 for ultrasound guidance (one unit following Medicare rules)
• 88172 x 2 for FNA immediate adequacy checks from each of two distinct thyroid nodules
• +88177 for second immediate adequacy check for specimen A
• 88173 x 2 for FNA evaluation and report for each of two distinct thyroid nodules
• 88342 x 2 for two IHC stains on specimen A
• 88305 for cell block from specimen A.