Pathology/Lab Coding Alert

Beware pathologist’s dual role.

When your pathologist performs both the fine needle aspiration (FNA) extraction and evaluation steps, you need to be on the lookout for potential coding pitfalls.

Read on for our experts’ advice on how compliance issues and statutory guidance from Medicare’s National Correct Coding Initiative (NCCI) impact your coding considering case variations such as image guidance, anatomic site, and the number of “passes” to acquire an adequate specimen.

Case 1: Guidance, Lesion(s) Focus Code Selection

The pathologist performs an FNA of a right thyroid nodule, plus an FNA of a nodule of the right thyroid isthmus — both without image guidance.

Because the case documents no image guidance, you should turn to the code family of 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion).

Other guidance options: CPT^® provides the following different code families for other guidance methods, although pathologists are less likely to perform these procedures:

• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• 10007 (Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion)
• 10009 (Fine needle aspiration biopsy, including CT guidance; first lesion)
• 10011 (Fine needle aspiration biopsy, including MR guidance; first lesion)

Count lesions: When reporting FNAs, keep count of lesions at different anatomic sites so that you can report the correct number of units. For each of the preceding codes that describes “first lesion,” CPT^® provides a child code for “each additional lesion,” as follows:

• Paired with 10005: +10006 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10007: +10008 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10009: +10010 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10011: +10012 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10021: +10004 (… each additional lesion (List separately in addition to code for primary procedure))

Documentation advice: Make sure your pathologist identifies the location of each lesion aspirated. Vague documentation habits can contribute to coding errors involving these needle procedures, says Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina.

NCCI guidance: Chapter 3, Section K.3, of the NCCI Policy Manual states, “The unit of service for fine needle aspiration biopsy, (CPT^® codes +10004-+10012 and 10021) is the separately identifiable lesion. … A separate unit of service may be reported for a separate aspiration biopsy of a distinct separately identifiable lesion.”

In other words, correctly coding these cases means you need to focus on the number of lesions the pathologist aspirates from different sites. In the case example above, you would report 10021 for the FNA on the first lesion (right thyroid lobe) and one unit of add-on code +10004 for the second lesion on the right thyroid isthmus.

Case 2: Beware of ‘Passes’

Whether the pathologist receives an FNA aspiration from another practitioner or obtains the specimen by performing the extraction, the pathologist will evaluate the aspirate to ensure that the specimen is adequate for pathologic examination and diagnosis. In this case, the pathologist determines that another extraction is needed to achieve a diagnostic specimen.

Key: The intra-operative adequacy check takes place while the patient is still in surgery, and the findings dictate whether another FNA “pass” from the same lesion is needed.

“But if another pass is needed from the same lesion, you should not bill an additional FNA extraction code such as 10021 or +10004,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA. Chapter 3 of the Manual concurs, stating “If a physician performs multiple ‘passes’ into the same lesion to obtain multiple specimens, only one unit of service may be reported.”

The examination side: The pathologist performs the adequacy check and bills 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site). If the specimen is inadequate, indicating the need for another FNA extraction from the same lesion, code +88177 (… each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)) describes a second pathology evaluation for adequacy.

NCCI guidance: Chapter 10, Section M.7 of the NCCI Policy Manual states, “An evaluation episode consists of examination of a set of cytologic material to determine whether the material is adequate for diagnosis.” The set of cytologic material could be from one pass or several passes from the same lesion. The Manual goes on to state, “The evaluation episode is independent of the number of passes of the needle into a lesion and the number of slides examined. A second or additional evaluation episode (i.e., CPT^® code +88177) cannot begin before an assessment is rendered by the pathologist to the operating physician, and the operating physician uses the assessment to determine whether additional needle passes should be performed.”

Compliance issue: Because this case involves two evaluation episodes, you could bill 88172 and +88177 for the pathologist’s work if another practitioner performed the FNA extraction. If the pathologist performs both the 10021 service and the 88172 service, however, convention holds that the pathologist should not bill +88177 for the second evaluation episode. This is a compliance issue and should not be done, to avoid the appearance of a financial conflict of interest.