Pathology/Lab Coding Alert

Question: A pathologist receives a slide, which is said to be prepared from a breast fine needle aspiration. The pathologist notes that it is a cellular specimen, but he signs the case out with a diagnosis of cellular sample insufficient for diagnosis. Is there a billable CPT code for that diagnosis? Can we bill for the interpretation?

Mississippi Subscriber

Answer: If the specimen was reviewed immediately after the procedure to determine if the slide contained adequate material, 88172 (evaluation of fine needle aspirate with or without preparation of smears; immediate cytohistologic study to determine adequacy of specimen[s]) should be coded. This code may be used only if the evaluation of the slide was done immediately.

If the evaluation was not performed immediately, whether it is billable depends on your practice guidelines. To bill insurance companies, a service must be provided; some facilities state that the physician did indeed provide a service by looking at the slide and reporting an opinion regardless of the diagnosis of the test. But other facilities do not feel comfortable charging for a service that was not completed according to the request for the service.

If your practice has no policy for this, the issue should be discuss within the department and a decision should be made. The policy should be written clearly and sent to hospital and physician offices, so they are know your policy.