Wiki FNA/FNAB - Can you bill 88173 and 88305 if no cell block was created but tissue was submitted

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llg2020

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Hi there!

I have a pathology coding question that I'm hoping you can help get answered.

Can you bill an 88305 and an 88172 if a cell block wasn't created but tissue was submitted for microscopic examination? Some believe you cannot bill for cytologic and surgical pathology CPT codes on the same specimen (in other words, not bill for the 88305 and just bill for the 88172/88173 even if tissue was submitted but cell block was not created from fluid).

More background info.. we are starting to seeing a new procedure where a fine needle aspirate needle is used to obtain a tissue sample. Along with the tissue sample, there is usually fluid in the needle as well that is also used to help render either a diagnosis or immediate adequacy check.

This particular procedure goes as follows: A hollowed out needle, like the one used for regular FNA's is inserted into the patient, a piece of gastric tissue is removed, and the needle contents is given to the pathologist in the OR. The following scenarios are possible options of what could happen next:

  • Scenario A: the tissue is removed from the needle and placed in formalin for it to be submitted in a cassette. The needle contents are then, for lack of a better word, squirted onto a slide and smears are created for immediate adequacy studies. The pathologist uses the smears prepared to determine whether spindle cells are present or not, and the information is relayed immediately to the surgeon. No fluid is submitted for cell block preparation.
    (appropriate codes:
    88305 x 1- tissue submission and
    88172 x 1 - immediate evaluation of cytologic fluid ?)

  • Scenario B: the contents of the needle are, again for lack of a better word, squirted onto a slide. Tissue is removed and placed in formalin for it to be submitted in a cassette. The fluid on the slide is used to create a smear for immediate adequacy check. No fluid is submitted for cell block preparation.
    (appropriate codes:
    88305 x 1- tissue submission and
    88333 x 1 - immediate evaluation of TP, since tissue was placed on slide used for smear review prior to being submitted into individual cassette. ?)

  • Scenario C: tissue is removed from the needle and placed in formalin for it to be submitted in a cassette. Some of remaining needle contents are placed on slide for immediate evaluation, and the rest is submitted in cytorich media for cell block.
    (appropriate codes:
    88305 x 1- cell block
    88172 x 1 - immediate evaluation of cytologic fluid
    88173 x 1 - fna review?)

The main question, I believe, is can you bill an 88305 and an 88172 if a cell block wasn't created but tissue was submitted for microscopic examination? Some believe you cannot bill for cytologic and surgical pathology CPT codes on the same specimen (in other words, not bill for the 88305 and just bill for the 88172/88173 even if tissue was submitted but cell block was not created from fluid).

Any help would be greatly appreciated!

Thank you,
 
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Hi llg2020,

Cytology coding can be very confusing at times, but I may be able to help. Needle core biopsies do occur all the time.

If a true fine needle aspiration did occur; documentation would need to support billing any FNA charges (88172/88173). It needs to state that "fine needle aspiration ......"

Look at your pathology report - what does it state?
Under the "gross description" what was received?

If it states "slides received" - then you will bill 88173 along with any immediate assessment (88172) if applicable

IN MY OPINION - If tissue was submitted separately for a gross and microscopic interpretation you would bill the appropriate biopsy code (based on location).

Example: if it states 3 core biopsies received measuring .7x.8x.8 measurements in aggregate from a location within the patient's body you would code the 8830x (depending on location - stomach, pancreas, lung, liver, etc for the tissue biopsy) and rapid assessment would be 88333 with 88334 (if appropriate).

I'm only here to help, if you wanted to throw a pathology report here with no PHI.
I know that I code many cytology and surgical cases that all occur on the same DOS (for example: lung FNA, lung biopsy, lymph node sampling bx all with different accessioning numbers). But, hmm - I also did wonder if this may be just a accessioning issue at your facility.

Thank you for listening,
Have a great evening.
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Coding Specialist 3 - Pathology
Coding Analyst & Denial Specialist
 
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I am bursting at the seams with exciting news to share regarding cytology coding! I have asked Dr. Dianne Kendall, MD (Duluth, MN) to speak virtually for our local chapter meeting on 6/1/2021 at 530 pm (CST) and she agreed today and I just submitted our chapter's "event request". She is such a phenomenal speaker and has presented for our chapter several years for our "MayMania" meeting and has provided us numerous tours to the pathology department. Which will not happen this year. Dr. Kendall really has a niche about explaining pathology and makes it so interesting and ALSO knows how to assign proper code assignment for CPT charges too. I don't have the details yet because I just submitted my event request a few moments ago today, but anyone that is interested in attending please visit our local chapter website Brainerd, MN for additional details if you would like to attend this exciting event!! I hope to see you there!!
 
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Question please. I know this thread is old but I need help. Do we always use the 88172 and the 88173 for every case? I have always used those two with 88104 and never had a problem. Now Medicare Advantage Blue Cross says that they are part of the 88104 and they would not pay. They were saying it was global. Is there a special modifier that should be used for this?
 
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Hi RobynKing,
Please simply never apologize if you need help. I'd rather have you just say "Dana - say would you taking a peek at this and tell me if I am tackling the coding correctly okay".
Okay let's review FNA (fine needle aspiration together). There is some "gray area" here so let me explain the possibilities here.

I have worked for facilities that the pathologist's did not perform the FNA (fine needle aspiration) and was not required to bill it ("except their professional fees" for the immediate evaluation with the interpretation). The technical charges were populated by those that performed the actual FNA procedure intraoperatively.
I'm just randomly coming up with examples for these cases off the top of my head - No PHI
Patient has a FNA (fine needle aspiration) performed by Surgeon J. Bond on their enlarged right cervical lymph node and a "rapid evaluation" is performed intraoperatively with final interpretation provided in the pathology report. We would bill 88172 with Modifier 26 and 88173 with modifier TC/26. The technical charges for the intraoperative FNA will be billed by Dr. James Bond that performed it - they would be responsible for reporting that charge.

I review documentation for one my pathology clients. Let's use same scenario as above - the pathologist Dr. Howdy performs the FNA (fine needle aspiration) using US guidance performed on the patient's enlarged right cervical lymph node and a "rapid" evaluation is performed intraoperatively with final interpretation of the pathology and documentation to support the intraoperative procedure in the pathology report also. We would bill the FNA charges with 10005 PB/TC or global, 88172 PB/TC or global and 88173 PB/TC or global. Unsure on circumstances so that is why I state PB/TC or global.

Again, the same company I review documentation for bills for all the intraoperative FNA (fine needle aspirations) performed regardless of who performs them). Same example the cytotechnician Jane Doe performs the intraoperative FNA (fine needle aspiration) using US guidance on the patient's enlarged right cervical lymph node and her slides are presented to the pathology department where again Dr. Howdy reviews and provides their professional interpretation in their pathology report. They would have billed 88172-TC, 88173 both TC and PB for this scenario. Cytotechnician would be responsible for posting their own charges for the 10005 FNA biopsy including US guidance.

To answer your question if we should always bill 88172 with 88173 - that depends entirely on the scenario. The rapid evaluation should be done "immediately" or "intraoperatively" from my experience billing charges related to 88172 ~ unless someone else has otherwise to share on this. The interpretation will be billed with 88173.

Medicare is not going to pay for 88104 billed with 88173 on the same DOS (day of service); I already know that from working denials that even with a properly applied modifier that they bundle those charges (88104/88173) and they will require a "redetermination" (very similar to an appeal process but only with Medicare claims - no corrections were performed, and the biller attaches the documentation [separate accessions] to support billing those charge within the 120 days from the remittance date).

The questions I need to ask you from your post:
1) Were all the charges from the same pathology specimen or were there two accessions (different specimens) from your billing scenario above?
2) You stated they are bundling 88172 & 88173 into 88104. Again, this is my professional opinion ~ if it is the same specimen source, we would not want to bill 88172, 88173. with 88104. Simply do not bill out 88104. Personally myself, I would have simply omitted the 88104 and billed the other two remaining charges 88172 with 88173 if that is really what had happened.

Again, I am hopeful that I am providing examples that you can compare your notes too. If I have missed something ~ please be sure to reach out and say something. If you are questioning or unsure if a rapid/immediate/intraoperative FNA is actually being performed to justify actually billing procedure 88172. Just provide a simple (No PHI) basic note.

I am going to share with you that I have been doing the pathology specialty for 10 years (my very first passion and also first specialty since day one) I still TODAY question everything "all the time" (review my other posts, some very recent, please) in my book there should be no shaming by anyone. 10 years ago, I had limited resources and reviewed "homework" online from any "solid" source I could find - seriously my advice to any pathology coder is please find credible resources to back your reasoning for your coding assignment (interpretation) on diagnosis code(s) assignment. Anyone's compliance department will always ask you this "almighty question" if faced with an RAC audit- what was the rationale? Did you code this scenario "every time"? I want all my pathology colleagues to feel comfortable asking questions anytime please. I'm 10 years into this specialty and I am still asking questions - please don't ever be afraid.
Thank you for your question, I'm hopeful you have the answers and have a wonderful evening.
Thank you for listening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
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danachock said:
Hi RobynKing,
Please simply never apologize if you need help. I'd rather have you just say "Dana - say would you taking a peek at this and tell me if I am tackling the coding correctly okay".
Okay let's review FNA (fine needle aspiration together). There is some "gray area" here so let me explain the possibilities here.

I have worked for facilities that the pathologist's did not perform the FNA (fine needle aspiration) and was not required to bill it ("except their professional fees" for the immediate evaluation with the interpretation). The technical charges were populated by those that performed the actual FNA procedure intraoperatively.
I'm just randomly coming up with examples for these cases off the top of my head - No PHI
Patient has a FNA (fine needle aspiration) performed by Surgeon J. Bond on their enlarged right cervical lymph node and a "rapid evaluation" is performed intraoperatively with final interpretation provided in the pathology report. We would bill 88172 with Modifier 26 and 88173 with modifier TC/26. The technical charges for the intraoperative FNA will be billed by Dr. James Bond that performed it - they would be responsible for reporting that charge.

I review documentation for one my pathology clients. Let's use same scenario as above - the pathologist Dr. Howdy performs the FNA (fine needle aspiration) using US guidance performed on the patient's enlarged right cervical lymph node and a "rapid" evaluation is performed intraoperatively with final interpretation of the pathology and documentation to support the intraoperative procedure in the pathology report also. We would bill the FNA charges with 10005 PB/TC or global, 88172 PB/TC or global and 88173 PB/TC or global. Unsure on circumstances so that is why I state PB/TC or global.

Again, the same company I review documentation for bills for all the intraoperative FNA (fine needle aspirations) performed regardless of who performs them). Same example the cytotechnician Jane Doe performs the intraoperative FNA (fine needle aspiration) using US guidance on the patient's enlarged right cervical lymph node and her slides are presented to the pathology department where again Dr. Howdy reviews and provides their professional interpretation in their pathology report. They would have billed 88172-TC, 88173 both TC and PB for this scenario. Cytotechnician would be responsible for posting their own charges for the 10005 FNA biopsy including US guidance.

To answer your question if we should always bill 88172 with 88173 - that depends entirely on the scenario. The rapid evaluation should be done "immediately" or "intraoperatively" from my experience billing charges related to 88172 ~ unless someone else has otherwise to share on this. The interpretation will be billed with 88173.

Medicare is not going to pay for 88104 billed with 88173 on the same DOS (day of service); I already know that from working denials that even with a properly applied modifier that they bundle those charges (88104/88173) and they will require a "redetermination" (very similar to an appeal process but only with Medicare claims - no corrections were performed, and the biller attaches the documentation [separate accessions] to support billing those charge within the 120 days from the remittance date).

The questions I need to ask you from your post:
1) Were all the charges from the same pathology specimen or were there two accessions (different specimens) from your billing scenario above?
2) You stated they are bundling 88172 & 88173 into 88104. Again, this is my professional opinion ~ if it is the same specimen source, we would not want to bill 88172, 88173. with 88104. Simply do not bill out 88104. Personally myself, I would have simply omitted the 88104 and billed the other two remaining charges 88172 with 88173 if that is really what had happened.

Again, I am hopeful that I am providing examples that you can compare your notes too. If I have missed something ~ please be sure to reach out and say something. If you are questioning or unsure if a rapid/immediate/intraoperative FNA is actually being performed to justify actually billing procedure 88172. Just provide a simple (No PHI) basic note.

I am going to share with you that I have been doing the pathology specialty for 10 years (my very first passion and also first specialty since day one) I still TODAY question everything "all the time" (review my other posts, some very recent, please) in my book there should be no shaming by anyone. 10 years ago, I had limited resources and reviewed "homework" online from any "solid" source I could find - seriously my advice to any pathology coder is please find credible resources to back your reasoning for your coding assignment (interpretation) on diagnosis code(s) assignment. Anyone's compliance department will always ask you this "almighty question" if faced with an RAC audit- what was the rationale? Did you code this scenario "every time"? I want all my pathology colleagues to feel comfortable asking questions anytime please. I'm 10 years into this specialty and I am still asking questions - please don't ever be afraid.
Thank you for your question, I'm hopeful you have the answers and have a wonderful evening.
Thank you for listening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
Click to expand...
 
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So, you are saying don't bill out the 88104. Are you meaning don't bill it out for the same date of service as the 88173,88172? I have cases that are 5 pages. 3 are for the 88104 and two are for the 88172,88173. I don't want to loose out on the money for my doctor on those 88104's.
 
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