Pathology/Lab Coding Alert

Evaluation coding stays the same.

When your pathologist extracts a fine needle aspiration (FNA) specimen from a patient, you currently have two codes to choose from – but that is about to change.

On Jan. 1, CPT^® 2019 deletes one of the existing FNA extraction codes and revises the other. That’s just the start of what you need to know, because CPT^® 2019 also adds nine new FNA extraction codes. Read on to get the lowdown on how to code these services next year.

Study FNA Extraction Code Changes

Let’s get started by learning how CPT^® 2019 changes the existing FNA extraction codes, as follows:

• 10021 (Fine needle aspiration biopsy, without imaging guidance; without imaging guidance first lesion) Notice that the revised definition specifies that the FNA is a type of biopsy, and that you should use this code for the first lesion sampled using this method. The code continues to describe an FNA extraction performed without imaging guidance
• 10022 (… with imaging guidance) CPT^® 2019 deletes this code. Currently, if the pathologist performs the 10022 service, an additional code describes the specific imaging service, such as 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). That changes on Jan. 1 when you’ll have multiple codes to describe FNA extraction with imaging guidance included.

New codes: Here are the eight new FNA codes that bundle imaging guidance:

• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• +10006 (… each additional lesion (List separately in addition to code for primary procedure))
• 10007 (Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion)
• +10008 (… each additional lesion (List separately in addition to code for primary procedure))
• 10009 (Fine needle aspiration biopsy, including CT guidance; first lesion)
• +10010 (… each additional lesion (List separately in addition to code for primary procedure))
• 10011 (Fine needle aspiration biopsy, including MR guidance; first lesion)
• +10012 (… each additional lesion (List separately in addition to code for primary procedure)).

“These new codes reflect a change happening throughout CPT^® to include the radiology procedures as part of the primary procedure code, rather than billing separately for them,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Here’s why: “Each year the AMA’s Relativity Assessment Workgroup evaluates potential mis-valued codes to determine whether two codes are performed together at least 75 percent of the time,” says Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York. “If two codes are typically performed in conjunction with one another, a single combination code that more accurately depicts the services may be created,” Corney explains.

In the case of 10022, the AMA’s Relativity Assessment Workgroup referred the code to the CPT^® Editorial Panel because of findings that certain providers bundle 10022 with ultrasound code 76942 more than 75 percent of the time.

One more new code: You’ll notice that CPT^® 2019 pairs the new “with imaging guidance” codes as a parent code for the first lesion, and an add-on code for each additional lesion. To create the same hierarchy for the “without imaging guidance” code, CPT^® 2019 adds +10004 (Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)). You should report +10004 in addition to revised code 10021, when appropriate.

Tip: Most pathologists who perform an FNA extraction procedure will do so without image guidance, or possibly with ultrasound guidance. That means as a pathology coder, you might turn to 10021 and +10004 most often, and 10005 and +10006 more often than the other new codes.

Stay Constant in FNA Evaluation Coding

The unit of service for an FNA extraction procedure (current codes 10021 and 10022) has never directly aligned with the unit of service for some of the FNA evaluation procedures that the pathologist performs. The discrepancy has led to some coder confusion, and the new extraction codes could exacerbate that lack of clarity.

Constant: The unit of service for an FNA extraction procedure has been, and will remain in 2019, per lesion. “Whether the pathologist sticks the needle into the lesion one or multiple times to extract cellular material, you should report the FNA extraction code just once fora single lesion,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Change: By creating the new FNA add-on codes, CPT^® 2019 now provides a new way to report FNA extraction from multiple lesions on a single day, but the unit of service remains “per lesion.” The new way to report multiple lesions is to use the parent code for the first lesion extraction by a specific procedure (without guidance or with a specific guidance method), and the associated add-on code for each subsequent lesion extraction by the same method for a different lesion.

Evaluation is different: The unit of service for an FNA evaluation for specimen adequacy is not “per lesion;” it is per “evaluation episode.” CPT^® describes the evaluation episode this way: “The evaluation episode represents a complete set of cytologic material submitted for evaluation and is independent of the number of needle passes or slides prepared. A separate evaluation episode occurs if the proceduralist provider obtains additional material from the same site, based on the prior immediate adequacy assessment, or a separate lesion is aspirated.”

With that definition in mind, you can better understand how to report the following FNA codes for specimen-adequacy evaluation:

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

Do this: “You should report 88172 for the first evaluation episode from a single lesion, and one unit of +88177 for each additional evaluation episode from the same lesion,” explains Peggy Slagle, CPC, coding and compliance manager for the department of pathology/microbiology at the University of Nebraska Medical Center in Omaha.

Difference: The unit of service for the final FNA evaluation with interpretation and report (88173, Cytopathology, evaluation of fine needle aspirate; interpretation and report) is not the evaluation episode — it’s back to “per lesion,” just like the extraction codes.

CPT^® puts it this way in a text note following 88173: “Report one unit of 88173 for the interpretation and report from each anatomic site, regardless of the number of passes or evaluation episodes performed during the aspiration procedure.”