Pathology/Lab Coding Alert

Question: Our pathologist performed a fine needle aspiration for a cervical cyst and evaluated the fluid to ensure adequacy. The final cytology report was benign and showed non-specific inflammatory cells. The pathologist stated that it was a Nabothian cyst. How should we code the procedure and the diagnosis?

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Answer: You should report CPT® codes for the pathologist acquiring and evaluating the fine needle aspiration (FNA) specimen, as well as for the FNA cytology diagnosis. Report the diagnosis based on the cytology findings.

Procedure: List the FNA aspiration and diagnosis steps as follows:

• 10021 -- Fine needle aspiration; without imaging guidance
• 88172 -- Cytopathology evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, fist evaluation episode, each site
• 88173 -- ... interpretation and report.

Report the diagnosis as 616.0 (Cervicitis and endocervicitis). ICD-9 lists Nabothian (gland) cyst or follicle in the "includes" list for this code.