Pathology/Lab Coding Alert

Question: Our pathologist examined an FNA of right thryoid, specimen, which was inadequate for diagnosis. At this point the surgeon decided to perform a core biopsy. The pathologist also examined an FNA of a nodule in right isthmus, which the pathologist determined was inadequate for diagnosis. The surgeon proceeded to submit a core biopsy of right isthmic nodule.Can we code for the FNA x 2 and core biopsies x 2.

Wisconsin Subscriber

Answer: You should code the case as follows:

·         FNA right thyroid, inadequate specimen: 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site)

·         Thyroid core biopsy: 88305 (Level IV - Surgical pathology, gross and microscopic examination…). Although it’s not a listed specimen, coding convention equates the thyroid biopsy with a sinus or tonsil biopsy in terms of physician work.

·         FNA of right isthmus, thyroid: 88172. Although this is the second FNA adequacy check, it is the first one on this site of the thyroid, so you should not report 88177 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site [List separately in addition to code for primary procedure]).

·         Core biopsy of nodule in right thyroid isthmus: 88305, for the same reasons as the right thyroid biopsy.

Depending on the payer, you may report this as 88172x2 and 88305x2, or you may need modifiers to indicate that you’ve examined distinct specimens, such as 59 (Distinct procedural service).