Pathology/Lab Coding Alert

Question: We received 400 cc of fluid from a pelvic washing that we processed as three cytospin papanicolaou slides and a cell block. Our pathologist examined the concentrated smears plus four H&E slides from the cell block. How should we code this?

Indiana Subscriber

Answer: You-ve described a cytology specimen that fits into the non-gynecological category of codes 88104-88112. You choose among those codes based on the method the lab uses to process the cytology specimen. In your case, you describe a concentration technique (cytospin), so you should report the service as 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]).

Because you also prepare a cell block from the specimen, you should report that as an additional procedure. Use 88305 (Level IV -- Surgical pathology, gross and microscopic examination, cell block, any source).

The stains that you mention -- papanicolaou and hematoxylin and eosin (H&E) -- are standard stains, so you should not list an additional "special stain" code such as +88312 (Special stains [list separately in addition to code for primary service]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) or +88313 (- Group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each).

Although you list the number of slides for the smear and the cell block, that information is not relevant to how you should code this case. You should list one unit of service for the cytology and one unit of service for the cell block regardless of the number of slides.

Bottom line: You should code the case as 88108 and 88305. Because you indicate that one billing entity performs both the specimen preparation and interpretation, you do not need to use modifiers TC (Technical component) or 26 (Professional component). Listing the unmodified codes means that you are billing for the global service.