Pathology/Lab Coding Alert

Answer: Yes, you can separately report the fine needle aspiration (FNA) extraction, adequacy check, and pathology diagnosis. With proper documentation of bilateral breast specimens, you can separately report the work for left and right breast, but that doesn’t always mean two units of each code.

Report the initial breast FNA extraction as 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion) and the second breast FNA extraction as +10004 (Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)).

Remember that 10021 has a medically unlikely edit (MUE) of 1. This means that you may report only one unit of 10021 on any given date of service (DOS). Reporting 10021 separately with modifiers LT (Left side) and RT (Right side) is inappropriate, and the payer will deny the service.

Consider the following CPT^® Assistant guidelines:

• “Codes +10004-+10012 and 10021 may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, on the same day, and using the same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).”

Adequacy: Because the pathologist documents examining each FNA specimen to determine if adequate cells are present for diagnosis, you may report two units of 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site).

Interpretation: Finally, the pathologist’s work earns two units of 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report), one for each separate lesion diagnosis.

Modifiers: To avoid confusion, modifiers such as LT (Left side) and RT (Right side) may clarify that the adequacy check and interpretation services are for distinct lesions from the left and right breasts. Your payer may prefer that you use other modifiers, such as 59 (Distinct procedural service) or XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure).