Revenue Cycle Insider

Question: Our pathologist performed a fine needle aspiration (FNA) on a patient’s breast, then examined the aspirate using selective cellular enhancement. In addition to billing for the FNA and the evaluation and report of the specimen, can we also bill for the cellular enhancement?

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Answer: No, you cannot report 88112 (Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal) in addition to 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) for the cytology evaluation. That’s because 88173 includes the smear preparation and the evaluation for the specimen.

However, if your pathologist performed a breast cyst puncture billed with 19000 (Puncture aspiration of cyst of breast) instead of the FNA billed with 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion), you would report the 88112 for the specimen preparation and interpretation.

Remember: If the glass microscope slides are digitized, you’ll report 0837T (Digitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; interpretation and report (List separately in addition to code for primary procedure)) along with 88173 and 0830T (Digitization of glass microscope slides for cytopathology, selective-cellular enhancement technique with interpretation (eg, liquid-based slide preparation method), except cervical or vaginal (List separately in addition to code for primary procedure)) with 88112.

Also, if the pathologist uses ultrasound guidance for either of the two cytopathology techniques, you will report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) with 19000 but not with 10005, as ultrasound guidance is included in the code for the FNA procedure.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC