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Pathology/Lab Coding Alert

Reader Question:

Breast Sampling Method Controls Code

Published on Wed Jan 01, 2003

Question: Should we code the interpretation of a breast fine-needle aspirate (FNA) differently depending on whether we prepare the cells as direct smears or thin-layer cytology? What if we perform a touch prep of a breast needle core biopsy to determine adequacy, rather than a smear or a thin-layer prep from an FNA? Kansas Subscriber Answer: Report the pathologist's interpretation and report on an FNA specimen as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) regardless of whether the lab prepares direct smears or liquid-based cytology slides.

If the pathologist performs a needle-core biopsy and touch preps for adequacy, code the touch prep using 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation). If the pathologist performs the touch prep intraoperatively and reports the findings to the physician regarding the adequacy of the biopsy specimen, also report 88329 (Pathology consultation during surgery). Finally, report the pathologist's interpretation of the breast biopsy specimen as 88305 (Level IV Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins).
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