Pathology/Lab Coding Alert

Look to the surgical procedure to define the specimen

Between 88104 and CPT 88173 , you can lose $81 if you don't get the breast-aspiration interpretation code right.

That's why the pathologist has to know how and why the surgeon extracted the cells before indicating the specimen in the pathology report.

Distinguish FNA Sample

Physicians often use fine needle aspiration (10021, Fine needle aspiration; without imaging guidance; or 10022, - with imaging guidance) to obtain a cellular specimen from a breast mass for diagnosis, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M. The physician inserts a thin needle into the breast mass and uses the syringe to extract cells.

Specimen interpretation code: When a pathologist provides a diagnosis by examining these cells, report 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). Use this code for FNA of the breast or any other location.

Don't miss: If the pathologist initially checks the aspirate under the microscope to ensure an adequate sample for diagnosis, you should report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]), Witt says. You can report 88172 for each -pass- that the pathologist examines for adequacy.

Key: You should code separately for each step of the FNA that the pathologist performs--from extraction (10021 or 10022) to adequacy check (88172) to FNA interpretation (88173).

Caution: Code 88173 includes interpretation of all slides examined from the aspirate regardless of slide preparation method--don't report 88173 with any other non-gyn cytology codes 88104-88112.

Puncture Aspiration Yields Different Specimen

Because an FNA specimen is similar to cellular material from other types of breast aspiration procedures, you may not be sure which code describes the pathologist's specimen exam. If the report says -breast cytology- or -breast tumor cells,- that's not enough information to code the pathology interpretation service.

Hint: There are two ways to quickly tell the difference between FNA and other aspirations:

1. FNA involves a thin needle extracting a small sample of cells (10021 or 10022), while a cyst aspiration involves a larger needle that extracts all of the contents of a cyst (19000, Puncture aspiration of cyst of breast; and +19001, ... each additional cyst [list separately in addition to code for primary procedure]).

2. A physician may order an FNA from a breast lesion to get an initial cell type analysis. On the other hand, physicians use cyst aspiration for treatment when a cyst becomes large and painful, or to rule out a solid mass, says Vaughn N. Bernard Jr., MD, FACS, a surgeon at Upper Cumberland Surgical Associates in Cookeville, Tenn. You might see a diagnosis code such as 610.0 (Solitary cyst of breast) or 610.1 (Diffuse cystic mastopathy).

Specimen interpretation code: When a pathologist examines direct smears from a breast cyst aspiration, report 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation). Use this code for direct cytology from any non-gynecological source, including breast--except FNA, which has its own code.
 
If you use the thin-layer preparation method for the breast aspirate, report 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid-based slide preparation method], except cervical or vaginal).

Select Single Specimen per Site

The National Correct Coding Initiative bundles 10021 and 10022 with many biopsy codes found throughout the CPT surgery sections, says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

For instance: NCCI bundles 10021 with 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]).

By listing FNA in column 2 with a multitude of biopsy codes under the -sequential procedures- policy, CMS indicates that the surgeon should not bill for an FNA extraction when followed at the same session by a biopsy of the same anatomic site.

Tip: The FNA/biopsy bundling does not extend to the pathologist's interpretation service. In most cases, you can bill separately for 88173 and a surgical pathology tissue exam such as 88305 (Level IV--Surgical pathology, gross and microscopic examination; breast, biopsy, not requiring microscopic evaluation of surgical margins) even if the surgeon follows an FNA with a biopsy of the same site.