Pathology/Lab Coding Alert

Question: The cytology lab performs an exam of a pleural effusion specimen (obtained through thoracentesis). We use a liquidbased slide preparation method, and the exam finds malignant cells. What are the correct procedure and diagnosis codes?Tennessee SubscriberAnswer: You should report the cytology exam based on the lab method used, and the diagnosis code that confirms the presence of malignant cells in the fluid.Based on your description, the appropriate procedure code for the service is 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal). If the lab used a direct smear or concentration technique, you would choose a different code from the range 88104-88107 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; ...) or 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]).The appropriate diagnosis code is 511.81 (Malignant pleural effusion) to demonstrate the malignant cells findings. A note with [...]