Pathology/Lab Coding Alert

Question: Our pathologist examined a cytology specimen obtained when the surgeon drained an “infected hydrocele of testis” in a 25 year-old patient. What would be the appropriate CPT^® and ICD-10 codes for this case?

Texas Subscriber

Answer: The CPT^® code(s) will depend on how the pathologist processes the cytology specimen. A common procedure might be a thin layer preparation, which you should report as 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal). You’ll find other code choices in the range 88104-88108 (Cytopathology …).

Additionally, if the lab performs any tests to identify the infectious organism, you should separately report that service. For instance, lab studies might include a polymerase chain reaction (PCR) assay for Chlamydia trachomatis and Neisseria gonorrhoeae, which you should report as 87491 (Infectious agent detection by nucleic acid [DNA or RNA]; Chlamydia trachomatis, amplified probe technique) and 87591 (Infectious agent detection by nucleic acid [DNA or RNA]; Neisseria gonorrhoeae, amplified probe technique).

For an infected hydrocele, you should report N43.1 (infected hydrocele) as the diagnosis. But don’t stop there. ICD-10 guidelines direct you to include an additional code from B95-B97 to identify the infectious agent if known. If either of the tests for N. gonorrhoeae or C. Trachomatis is positive, you should additionally report B96.89 (Other specified bacterial agents as the cause of diseases classified elsewhere).