Pathology/Lab Coding Alert

Question: Our lab has a physician client who performs a lot of FNA procedures. Sometimes our lab receives prepared slides for interpretation by our pathologist, and sometimes we receive fluid identified as an FNA specimen, and we prepare the slides before our pathologist interprets them. How do we code the two different scenarios?

Virginia Subscriber

Answer: When you receive a fine needle aspiration (FNA) specimen from a single anatomic site for the pathologist’s interpretation, you should report 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). The same code applies whether you receive slides or fluid and prepare your own slides.

Code 88173 describes the professional interpretation of the FNA specimen, and

is the single code you should use whether the specimen is for one or more FNA extraction “passes” or “evaluation episodes” described by code 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site).

You should not use another cytopathology code from the range 88104-88112 (Cytopathology …) in addition to or instead of 88173. Codes 88104-88112 are for other cellular specimen sources such as fluids, washings, brushings, or smears that don’t have another more specific code. CPT^® provides specific codes for FNA or cervical/vaginal smears, so you should not use 88104-88112 for those specimens.