Pathology/Lab Coding Alert

Question: The pathologist received a pelvis cyst needle-aspiration specimen and examined the specimen as a direct smear. Should we code the cytology exam as an FNA since it was a needle specimen? The surgical procedure was 50390 (Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous).

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Answer: No, you should not use a code for evaluation of fine needle aspiration (FNA) for this specimen. Instead of 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report), you should report 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation).

Not every needle specimen is an FNA specimen. In this case, you’re dealing with a cytology specimen that is fluid drained from a cyst. You should choose the appropriate code based on how the lab processes the cytology specimen. In this case, the pathologist examines a direct smear, so the appropriate code is 88014.