Pathology/Lab Coding Alert

Question: If examination of aspirate from bone marrow needle biopsy (85102) requires the preparation of more than five slides, should CPT 88162 (cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains) be reported as well? If multiple cell blocks are prepared from the aspirate, should each cell block be coded 88305 (level IV surgical pathology, gross and microscopic examination)?

Georgia Subscriber

Answer: If both procedures are performed, bone marrow needle biopsy and bone marrow aspiration, two codes should be reported. Codes 85102 (bone marrow biopsy, needle or trocar) and 85095 (bone marrow; aspiration only) should be assigned because both procedures involve separate techniques to obtain different specimens. If the aspirate material is used for the smear interpretation only, with or without differential cell count, use code 85097 (bone marrow; smear interpretation only, with or without differential cell count). If the physician both aspirates and interprets and smears, code both 85095 and 85097.

In addition, code 88305 should be used for interpretation for each specimen/cell block; assign code 88305 and put the number of specimens (for example, five) in the unit column of the claim form. An interpretation/report must be documented for each specimen.

The following codes are used for pathologic examination:

85097examination of the bone marrow smear

88305examination of the bone marrow cell block prepared from the smear

88305examination of the bone marrow biopsy

88307examination of the bone biopsy

88311decalcification of bone marrow biopsy or bone biopsy

Editors note: If only physician services are performed, the codes 85095 and 85097 are reported with modifier 26 (professional component), if technical services (such as staining) are also performed, then the codes should be used without a CPT modifier.

Laurie Castillo, MA, CPC, president and curriculum instructor of the American Association of Professional Coders, Northern Virginia Chapter, ansd owner of Physician Coding & Compliance Consulting, a consulting firm in Manassas, VA, provided answers to the reader questions.