Pathology/Lab Coding Alert

Question: For an FNA evaluation, the pathologist wrote a final diagnosis of “insufficient for evaluation.” But in the microscopic description, he wrote “the specimen consists of predominantly blood with rare stromal cells.” Can I bill this FNA evaluation? 

California Subscriber

Answer: Your pathologist’s documentation makes billing this case difficult. 

You should not bill a pathologist’s fine needle aspiration (FNA) evaluation (88173, Cytopathology, evaluation of fine needle aspirate; interpretation and report) if the specimen contains no cells, meaning that there’s literally nothing to evaluate. The diagnostic statement makes it sound like that’s what you’re dealing with.

But the pathologist’s microscopic description makes it clear that he did find and evaluate cellular elements in the FNA specimen. 

You should talk to the pathologist about creating a diagnosis statement that reflects his findings as described in the microscopic section— even if it’s just normal cells. Using a phrase like “insufficient for evaluation” is a red flag to an auditor, who might legitimately argue that the pathologist didn’t have a specimen to perform a service.