Pathology/Lab Coding Alert

Question: When our pathologist interprets an FNA, and then goes to the operating room to consult with the surgeon on the findings, can we code for both the FNA interpretation and a pathology surgical consultation?

Minnesota Subscriber

Answer: No, you cannot report both a fine-needle aspiration (FNA) interpretation and a pathology surgical consultation for reporting the FNA results during surgery.

When a pathologist evaluates a fine needle aspiration (FNA), report the service as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). The global charge for this code includes preparing, interpreting, and reporting.

Include the report: Pathologists often evaluate FNA specimens intraoperatively so the surgeon can use the findings to determine the need for a more invasive procedure. Because the FNA includes the pathologist's interpretation and report, you should not bill an additional code for consultation during surgery.

Edits disallow double billing: Because the 88173 service includes the reporting, the Correct Coding Initiative (CCI) edits bundle 88329 (Pathology consultation during surgery) with 88173.

Don't miss adequacy check: When the pathologist performs an immediate evaluation of an FNA specimen to determine adequacy, you should report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]). You should use 88172 in addition to the 88173 interpretation when the pathologist performs both services.