Pathology/Lab Coding Alert

Question: The pathology report states that the specimen is an “FNA cyst aspirate,” of a Baker’s cyst from the back of the patient’s knee. The lab prepares the slides using thin layer preparation methodology; how should we code the pathologist’s exam?

Arkansas Subscriber

Answer: The best code choice in this case appears to be 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal).

Treating a Baker’s cyst by draining it using aspiration is a common procedure, and it is different from a fine needle aspiration (FNA). Physicians typically perform FNA to help diagnose conditions that may demonstrate abnormal cells in the aspirate fluid, such as a thyroid mass.

You may need to check with the pathologist to ensure that this really is a cyst drainage aspiration specimen, not a fine needle aspirate (FNA).

If you get clarification that the specimen is indeed an FNA, you should report the service as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) regardless of the way the lab prepared the slides (such as direct smear or liquid-based preparation).