Pathology/Lab Coding Alert

Question: I have a pathology report in which the "specimen" line states "prostate needle." I don't know how to code this pathology exam - any suggestions?

Mississippi Subscriber

Answer: You are astute to note that "prostate needle" is not enough information to define a specimen so that you can select the correct code for the pathologist's specimen exam.

Two directions: When using a needle to sample the prostate gland, the surgeon might take one of two paths. The surgeon might take a prostate needle biopsy (PNB) specimen, which is a small piece of tissue extracted through a hollow-core needle. Or, a surgeon might take a fine needle aspiration (FNA) specimen, which is a fluid "aspirate" of cells extracted from the organ through a small needle.

Even though the specimen line of the report doesn't reveal enough, further details in the pathology report should give you enough information to determine if the specimen is tissue or an aspirate.

Look for: Does the pathology report describe tissue processing, such as "submitted representative sections in two cassettes" or "formalin fixed paraffin embedded tissue?" Does the pathology report list the surgical procedure, such as PNB? Any of these phrases would indicate a tissue specimen, and the appropriate code would be 88305 (Level IV - Surgical pathology, gross and microscopic examination ... needle biopsy Prostate ...).

Or does the pathology report use terms such as "evaluation of fine needle aspirate" or "cytohistologic study," or list the surgical procedure as FNA? Any of these phrases would indicate that you should code a cytology FNA specimen.

In that case, you'll need to select the correct FNA code(s) based on other details in the pathology report. You might report one or more of the following codes for these services:

• 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site)
• 88173 (... interpretation and report)
• +88177 (... immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)).