Pathology/Lab Coding Alert

Question: We received drainage from a lymph node abscess. The pathologist examined a direct smear and reported findings of infection, then sent some of the specimen for culture. The culture resulted in a diagnosis of Staphylococcus infection. How should we code the case?

Kentucky Subscriber

Answer: The correct code for the direct smear fluid exam is 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation).

Although there are surgical pathology codes for abscess (88304, Level III - Surgical pathology, gross and microscopic examination, abscess) and lymph node biopsy (88305, Level IV - Surgical pathology, gross and microscopic examination, lymph node, biopsy), neither of those codes appear to be the correct choice in this case. You describe receiving “drainage” from a lymph node abscess and describe the specimen as fluid. If the specimen were a lymph node biopsy or the abscess capsule, you’d see tissue description and diagnoses, such as granulation tissue, in the pathology report.

Because the lab performs a culture and identifies a Staphylococcus infection, you should also charge for 87070 (Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates).

Presumptive identification involves identification by colony morphology, growth on selective media, Gram stains, or up to three tests (e.g., catalase, oxidase, indole, urease), according to CPT®.

There’s no evidence that you’ve performed additional tests on the culture and identified the organism to the species level, so you should not code additional microbiology codes such as 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate).