Pathology/Lab Coding Alert

Question: The pathologist diagnoses a CSF specimen that was collected in fluid and then concentrated and processed to eliminate debris and evaluated using computer assisted image analysis. How should we code this?

Montana Subscriber

Answer: You should report the procedure you describe using 88112 (Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal).

Remember: CPT^® divides cytopathology codes between “cervical or vaginal” and other sources. The other sources include fluids, washings, or brushings, such as cerebral spinal fluid (CSF) or bronchoalveolar lavage (BAL); or smears created by processes such as touching a tissue specimen to a slide or smearing nipple discharge or sputum on a slide; or fine needle aspiration (FNA) specimens.

Fluids: In your case, the specimen is a fluid, so the method used to evaluate the specimen, such as filtration or concentration, drives the code choice. Code 88112 describes a specific method, sometimes called “liquid based” cytology that involves enhancing the cells for analysis by removing background contamination and concentrating the diagnostic cells. That’s the procedure you described, leading you to select this code.