Pathology/Lab Coding Alert

Question: Our pathologist received three FNA specimens from three different breast lesions and two FNA specimens from a fourth breast lesion to check for specimen adequacy and diagnose, if adequate. Based on the adequacy check, one of the FNAs from the fourth lesion did not have sufficient cells. The pathologist diagnosed four FNA specimens. How should we code this?

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Answer: The correct coding is four units of 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site) for the adequacy check and four units of 88173 (… interpretation and report) for the final diagnosis.

Because the FNAs are from four distinct sites, it is appropriate to code them separately, both for the adequacy check and the final diagnosis.

Pitfall: Because the pathologist examined two FNA specimens for adequacy from a single site, you might be tempted to code that work 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]). But that would be wrong.

Here’s why: An “evaluation episode” is “the complete set of cytologic material submitted for evaluation and is independent of the number of needle passes,” according to CPT® instruction. You can bill for an additional evaluation episode using +88177 only if the pathologist receives a later FNA, typically after determining inadequacy of the first FNA.