Pathology/Lab Coding Alert

Question: Our pathologist examined an FNA specimen from a nodule in the right oropharyngeal isthmus. He determined that the specimen wasn’t adequate for evaluation, but rather than performing another FNA, the surgeon performed a core needle biopsy of the nodule. Should we report 88173 and 88305 for the case?

Connecticut Subscriber

Answer: Your coding recommendation is partially correct.

For the core needle biopsy of a nodule of the oropharyngeal isthmus, report 88305 (Level IV - Surgical pathology, gross and microscopic examination, nasopharynx/oropharynx, biopsy).

However, you should not report 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report), because the pathologist did not evaluate the FNA and provide an interpretation and diagnosis.

Do this: Instead, report your pathologist’s exam of the FNA specimen as an "adequacy check" using code 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site).