Pathology/Lab Coding Alert

Question: We often receive cytology specimens for evaluation that are not clearly defined, therefore we don't know how to code them. For example, the requisition may identify the source as "breast" but not state the method of acquisition. Consequently, we don't know if the aspirate is an FNA or aspiration of a cyst. How should we report these evaluations?

Arkansas Subscriber

Answer: To report the cytopathology service, you must know what the specimen is. If the requisition leaves the source ambiguous, you need to ask the surgeon's office which code was billed for the specimen.

If the surgeon reported 10021 (Fine needle aspiration; without imaging guidance) or 10022 ( with imaging guidance), the pathologist should report 88173 (Cyto-pathology, evaluation of fine needle aspirate; interpretation and report).

However, if the surgeon reported a code for a puncture aspiration (e.g., 19000*, Puncture aspiration of cyst of breast), the pathologist should report 88104 (Cyto-pathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) or 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]), depending on the methodology.

And, if some of the aspirate was processed in a fixative to make a cell block, report 88305 (Level IV -Surgical pathology, gross and microscopic examination, cell block, any source).