Pathology/Lab Coding Alert

Question: During the fine needle aspiration (FNA) procedure, usually the aspirate is first examined to determine if there is sufficient material for interpretation. If a cytotechnologist assists on the FNA by making the smears and evaluating the specimen(s) for adequacy, can they charge for this service? Does the appropriate code have a technical and professional component? If so, does that have an impact on how it is reported?

California Subscriber

Answer: Report the examination of the aspirate with code 88172 (evaluation of fine needle aspirate with or without preparation of smears; immediate cytohistologic study to determine adequacy of specimen[s]).

A cytotechnologist under physician supervision may perform an evaluation of fine needle aspirate for adequacy, and it is billable. The evaluation is often performed to determine if the specimen is sufficient for the test, so the patient will not have to come back for a repeat aspiration. Code 88172 has a professional and technical component and can be billed as such.

Code 88173 (evaluation of fine needle aspirate with or without preparation of smears; interpretation and report) also should be coded with 88172 when both services are performed. The 88173 service represents the definitive interpretation of the aspirate, rather than determination of adequacy. Code 88173 also has a professional and technical component. If the components are billed by separate entities, the professional component should be reported with the modifier -26, and the technical component with the modifier -TC.