Pathology/Lab Coding Alert

Question: We have a disagreement in our office. If the pathologist examines a needle specimen from a breast cyst aspiration using thin-layer preparation for the slides, do we code 88112 or 88173?

Connecticut Subscriber

Answer: The correct code for a breast cyst aspiration specimen that your pathologist examines using thin-layer preparation slides is 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal).

You should reserve 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) for the pathologist’s evaluation of a fine needle aspiration (FNA) specimen.

Although both are “needle” specimens, the clinician performs a cyst aspiration to drain a fluid-filled cyst, which the pathologist then evaluates, while the clinician typically performs an FNA to withdraw cells from a solid mass for pathology diagnosis.

Coder tip: If you’re uncertain whether the specimen is a cyst aspiration or an FNA, you can use the surgical procedure as a guide. If the surgeon performs an FNA (such as 10021, Fine needle aspiration; without imaging guidance), you should report the pathologist’s exam as 88173. But if the surgeon performs a cyst puncture aspiration (such as 19000, Puncture aspiration of cyst of breast), you should code the pathology exam using a code such as 88112.