Pathology/Lab Coding Alert

Question: The pathologist documented evaluating two “passes” from a thyroid FNA for specimen adequacy. Can we bill two units of 88172?

Colorado Subscriber

Answer: How you bill your pathologist’s adequacy exam for fine needle aspiration (FNA) depends on more specific documentation than just the number of “passes,” which you don’t provide. The following three scenarios will demonstrate how further information impacts your code choice:

Scenario 1: The surgeon submits aspirate from two FNA passes of the right thyroid lobe. The pathologist examines both passes and reports back to the surgeon that one aspirate contains sufficient material for pathologic evaluation, so the surgeon closes the procedure with no further aspiration. You should bill this service as a single unit of 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site), because the two passes are from one site, and the pathologist examines the two passes in a single evaluation episode.

Scenario 2: The surgeon submits aspirate from a single FNA pass of the right thyroid lobe. The pathologist examines the aspirate and reports back to the surgeon that specimen does not contain sufficient material for pathologic evaluation. Based on that information, the surgeon performs a second FNA pass on the right thyroid lobe, which the pathologist examines and declares “sufficient.” You should bill this service as 88172 and +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)), because the pathologist performs two distinct evaluation episodes from the same site.

Scenario 3: The surgeon submits aspirate from a single FNA pass from the right thyroid lobe and a single FNA pass from the left thyroid lobe. The pathologist examines the two distinct specimens from two different sites and declares that both specimens are adequate for pathological evaluation. You should bill this service as two units of 88172, because the work involves the first evaluation episode for two different sites.