Pathology/Lab Coding Alert

Question: Sometimes our lab prepares FNA slides using methods other than direct smear. For instance, the pathologist may examine thin-layer preparation slides from a breast lesion FNA, or the lab may perform a cytospin on an FNA specimen before preparing slides. Does this change the coding?


Mississippi Subscriber


Answer: You should always report the pathologist's interpretation of a fine needle aspiration (FNA) as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report).

CPT provides other codes for non-gynecological cytology specimens based on lab method, such as the two you describe: 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal) or 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]). You should not use these to describe an FNA interpretation--CPT provides 88173 as the most specific code for that service.

Bottom line: Regardless of the number of slides or how the lab prepares them, the correct code for the pathologist's professional interpretation of an FNA specimen is 88173.