Pathology/Lab Coding Alert

Question: Our pathologist evaluated a fluid specimen from an ovarian cyst submitted by an oncologist. Should I code this as an FNA evaluation?

Arkansas Subscriber

Answer: The answer depends on the specimen source. In other words, did the oncologist perform a fine needle aspiration (FNA) or drain the cyst?

Evaluation of an FNA specimen involves examination and diagnosis of cellular material in an aspirate specimen. The appropriate code for that work is 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report).

On the other hand, evaluation of the fluid from draining a cyst is a cytopathology exam that you would code based on the evaluation method using a code from the range 88104-88112 (Cytopathology …).

For instance, if the exam involves enhancing the cellular content of the specimen using a method such as thin-layer preparation, you should report the service as 88112 (Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal).

Tip: You can use the procedure listed in the op report to guide your code selection: 88173 for an FNA or a code such as 88112 for cyst drainage.

Do this: See if the op report from the oncologist describes the procedure so you’ll know what kind of specimen your pathologist evaluated.