Pathology/Lab Coding Alert
Code Highest Level Cytology
Question: The cytopathology lab received a bladder washing specimen, reviewing a direct smear and processing the remainder as a ThinPrep slide for cellular enhancement. The pathologist documented urothelial carcinoma cells on the ThinPrep slide. What are the correct procedure and diagnosis codes for this case?
Georgia Subscriber
Answer: The correct procedure code for a ThinPrep bladder washing is 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical
or vaginal).
Despite also examining a direct smear slide, you should not additionally report 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) for a Medicare beneficiary, because the Correct Coding Initiative (CCI) lists 88104 as a column 2 code for 88112. You shouldn’t list the two procedures together for a single specimen. Many other payers follow Medicare rules on this point.
The appropriate diagnosis code for urothelial carcinoma is C67.9 (Malignant neoplasm of bladder, unspecified).
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