Pathology/Lab Coding Alert

Question: Our lab received a sputum specimen from an HIV/AIDS patient with suspected pneumocystosis sent to us in Saccomanno fluid. We-ve always billed 88160 for sputum, but someone has told us that we should bill 88108. Which is correct? 


Missouri Subscriber

Answer: You are correct that sputum is a non-gynecological, non-fluids/washing/brushing specimen that falls in the category of 88160 (Cytopathology, smears, any other source; screening and interpretation). However, the code is only appropriate for direct sputum smears.

If you concentrate the sputum, you should use the cytology concentration code 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]). Don't report both codes for the same specimen. Because both 88160 and 88108 include the -screening and interpretation service,- you need to choose the most accurate code.

You don't mention special stains in your question, but pathologists commonly look at a methenamine silver stain and/or a histochemical stain to help identify the causative organism, pneumocystis carinii. If your pathologist examines such special-stain slides, you should also report the following code(s):

- +88312--Special stains (list separately in addition to code for primary service); Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), each

- 88342--Immunohistochemistry (including tissue immunoperoxidase), each antibody.

Reader Questions were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.