Pathology/Lab Coding Alert

Question: Our pathologist often aspirates a breast lesion using a fine needle. When she examines the aspirate to see if there is adequate cellular material, then diagnoses concentrated-smear cytology slides from the specimen, how should we code the case?

New Jersey Subscriber

Answer: You should list a separate code for each procedure that your pathologist performs to complete this fine needle aspiration (FNA) case. For acquiring the FNA specimen, you'll have to use a code from the surgical CPT section. Report the service as 10021 (Fine needle aspiration; without imaging guidance).

Although CPT provides an alternate code for cases in which the physician uses imaging guidance to aspirate the lesion (10022, ... with imaging guidance), you didn't mention that your pathologist provided that service.

You should code the adequacy check as 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]).

For the FNA diagnosis, list 88173 (... interpretation and report).

Pitfall: Although you mention that the pathologist examined concentrated smears, you can't bill an additional cytopathology code such as 88108 (Cytopathology, concentration technique, smears and interpretation [e.g. Saccomanno technique]) for the concentration step. Code 88173 includes interpretation of all slides examined from the aspirate regardless of slide preparation method.