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Question: The pathologist extracted fluid during two fine needle aspiration (FNA) passes from a lesion in the patient’s right breast and evaluated the fluid for adequacy. For a left-breast lesion, the pathologist performed a separate FNA with adequacy check. Following the procedures, the pathologist examined and reported findings from each breast. How should we report the case?

Montana Subscriber

Answer: For the FNA extraction procedures, you should report 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion) for the lesion in the right breast and +10004 (… each additional lesion (List separately in addition to code for primary procedure)) for the left breast specimen.

Modifiers: You may add modifiers RT (Right side) to 10021 and LT (Left side) to +10004 to indicate the location of the two separate lesions.

Caution: Even though the pathologist performs the FNA in separate breasts, you should not list this case as 2 units of 10021 with modifiers RT and LT. The Centers for Medicare & Medicaid Services (CMS) assigns a medically unlikely edit (MUE) of 1 to code 10021, meaning that you can report only one unit of the code on any given date of service.

CPT^® Assistant states,“Codes +10004-10012 and 10021 may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, on the same day, and using the same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).”

Evaluation episode(s): You indicate that the pathologist evaluated both the right- and the left-breast FNA specimens for adequacy. That work earns 2 units of 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site), which you may also distinguish with modifiers RT and LT.

Pitfall: Despite the pathologist documenting two FNA passes in the right-breast lesion, you should not report 88172 for each pass. A CPT^® note following code 88172 states, “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, or a separate lesion is aspirated.”

Interpretation: When the pathologist finally interprets each FNA specimen and reports the histologic findings, you should report one unit of 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) for each specimen.

That’s because another CPT^® note following code 88173 tells you, “Report one unit of 88173 for the interpretation and report from each anatomic site, regardless of the number of passes or evaluation episodes performed during the aspiration procedure.”

Ellen Garver, BS, BA