Pathology/Lab Coding Alert

Question: I'm concerned about bundling rules for FNA and core biopsy performed together. If our pathologist examines an FNA and performs touch preps on a core biopsy for the same patient on the same day, how should we code the case?

Answer: Pathologists sometimes evaluate FNA specimens intraoperatively so the surgeon can use the findings to determine the need for additional aspirations from the same lesion, or for a more complex procedure like a needle-core biopsy.

Your stated bundling concern may relate to the fact that the Correct Coding Initiative (CCI) Policy Manual states that you should not report together a fine needle aspiration (FNA) (10021-10022, Fine needle aspirate; ...) and biopsy (such as 19100, Biopsy of breast; percutaneous needle core, not using imaging guidance [separate procedure]) from the same lesion unless one specimen is inadequate for diagnosis. But that restriction primarily constrains the surgeon. Your pathologist must depend on the surgeon to establish medical necessity of the procedures, and the pathologist will examine the specimens accordingly.

Real concern: CCI does list edit pairs for some pathology codes that will impact your coding by bundling both of the following FNA codes with both of the intraoperative touch prep codes:

• 88172 -- Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
• 88173 -- ... interpretation and report
• 88333 -- Pathology consultation during surgery; cytologic examination (e.g., touch prep, squash prep), initial site
• 88334 -- ... cytologic examination (e.g., touch prep, squash prep), each additional site (List separately in addition to code for primary procedure).

Here's why: You should not bill an FNA as an intraoperative consult just because it occurs during surgery. Always report the most specific codes to describe the FNA evaluation(s) -- 88172 and/or 88173 -- regardless of when or where the procedure occurs relative to surgery. As a CPT text note states, "do not report 88333 and 88334 for intraprocedural cytologic evaluation of fine needle aspirate, see 88172."

Nor should you bill for an intraoperative consult in addition to 88172 and 88173, because the FNA codes include evaluating slides and communicating results.

That said, if the surgeon submits two distinct specimens from the same lesion -- an FNA specimen and a core biopsy for intraoperative consultation -- your pathologist will perform some combination of 88172/88173 and 88333/88334 depending on the specifics of the case. Although CCI bundles these codes, you can legitimately override the edit pairs because the pathologist is examining separate specimens.

For example: If the pathologist performs an adequacy check for a breast FNA, and the surgeon proceeds to perform a needle core biopsy that the pathologist processes with an intraoperative touch prep, you should report 88333 plus 88172 -59 (Distinct procedural service) because 88172 is the column 2 code in the CCI edit pair. Don't forget to report 88305 (Level IV -- Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) when the pathologist diagnoses the core biopsy specimen.

The modifier should always go on the column 2 code -- 88333 is a column 2 code for 88173, and 88334 is a column 2 code for both 88172 and 88173.