Pathology/Lab Coding Alert

Reader Question:

FNA Adequacy Includes Opinion and Report

Question: I have been told that when the pathologist performs an intraoperative check for adequacy on an FNA specimen, we should report CPT 88172 and CPT 88329 for the service. Is this correct?

Utah Subscriber

Answer: No. For the service described by 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]), the pathologist looks at the FNA and determines if enough diagnostic cells are present. If not, the pathologist informs the physician aspirating the lesion to take another pass.

The 88172 service involves the pathologist rendering an opinion and reporting it. Code 88329 (Pathology consultation during surgery) also involves the pathologist rendering and reporting an opinion, so reporting 88329 in addition to 88172 for the same service would essentially be unbundling. Although National Correct Coding Initiative edits do not bundle these codes, you are still responsible for correct coding principles. Code 88172 is the most accurate code for the FNA adequacy determination.

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