Pathology/Lab Coding Alert

Question: From the pathology perspective, what is the difference between a fine needle aspiration specimen and needle biopsy specimen?


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Answer: A fine needle aspiration (FNA) specimen involves fluids and cellular material or free-floating bits of tissue that a physician has suctioned through a needle from a mass in the patient's body.

A needle biopsy typically involves a -core- of tissue that a physician has punched and removed via a hollow needle. The FNA needle is usually a smaller gauge, but not necessarily.

From a coding perspective for pathologists, the primary difference between the two specimens is that you would report the evaluation using different codes.

Report an FNA evaluation using two possible codes: 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) and 88173 (- interpretation and report). Your pathologist may perform either or both of these services for a single site that is under investigation by FNA.

During surgery, the pathologist may immediately examine slide(s) prepared from the FNA to determine if the specimen contains enough cells of diagnostic value--report that service as 88172. When the pathologist later examines the slide(s) and provides a diagnosis, report 88173.

For a needle biopsy pathology evaluation, you should report the appropriate code from the surgical pathology section based on the tissue source. For instance, report a needle-core breast biopsy as 88305 (Level IV--Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins).

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