Pathology/Lab Coding Alert

Question: During a breast fine needle aspiration (FNA), the surgeon submitted an aspirate to our pathologist for an adequacy check. Because the pathologist did not find enough cells for diagnosis, the surgeon aspirated and submitted a second sample from the same lesion for an adequacy check. The pathologist reviewed slides from the second pass and determined that enough material was present for diagnosis. Our pathologist later went on to examine the aspirate and provide a diagnostic report to the surgeon. How should we code this scenario?

Texas Subscriber

Answer: The answer to your question depends partly on the payer. The correct codes for the scenario are 88172 (Cytopathology, evaluation of fine needle aspirate;  mmediate cytohistologic study to determine adequacy of specimen[s]) and 88173 (...interpretation and report). The payer variation has to do with how many units of service you can report for the 88172 adequacy check.

Based on longstanding practice advocated by professional organizations such as the College of American Pathologists (CAP), the unit of service for the 88172 adequacy  heck is each aspirate or "pass." One pass represents one needle insertion with extraction of cellular material. If the pathologist determines that the aspirate from the first or subsequent pass does not contain sufficient cells for diagnosis, another aspirate is necessary before the patient leaves surgery, and the pathologist will perform another adequacy check on that aspirate.

Do this: Your example would warrant two units of 88172 based on the preceding understanding of how to use the codes. For payers that recognize this standard charge system, you should report the case in your example as 88172 x 2 and 88173.

Medicare is different: CMS changed the 88172 rules last fall for Medicare beneficiaries. The Correct Coding Initiative (CCI) Policy Manual version 15.3 states, "The unit  of service for CPT code 88172 is the separately identifiable lesion (tumor); ... all specimens from a single lesion are included in a single unit of service." The manual goes on to say that if a physician performs multiple "passes" into the same lesion to obtain multiple samples for immediate cytohistologic study, you can claim only one 88172 for all passes from a single lesion.

That doesn't mean you can never report two units of 88172. The policy manual states, "A separate unit of service may be reported for each distinct, separate lesion, but only one unit of service may be reported for all specimens from a single lesion." Because your example involves separate passes from the same lesion, you should report this case to Medicare as 88172 and 88173.