Pathology/Lab Coding Alert

Question: When our pathologist performs an FNA extraction, he generally documents speaking with the patient about the medical condition and performing a limited physical exam. Can we report an evaluation and management code such as 99241 in addition to the FNA extraction code?

Iowa Subscriber

Answer: When the pathologist performs the FNA extraction (10021, Fine needle aspiration; without imaging guidance), certain conditions might warrant an additional code for an E/M service such as 99241 (Office consultation a for new or established patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making).

To justify reporting the E/M code, the pathologist should meet three criteria:

1. The attending physician requests the pathologist's consultation, not just the surgical FNA procedure.

2. The pathologist has face-to-face contact with the patient and performs the components listed in the E/M code definition (history, exam and medical decision- making). The amount of time spent with the patient, not counting the time spent in the surgical procedure, should fit into the E/M guidelines. For instance CPT states that for 99241, "Physicians typically spend 15 minutes face-to-face with the patient and/or family."

3. The final report gives information beyond the cytologic diagnosis from the FNA. Because the E/M visit involves medical decision-making, the pathologist should interpret the findings from the exam, history and FNA diagnosis to reach a clinical conclusion and recommendations for further treatment.

Pathologists commonly perform FNAs in a non-inpatient setting, so you should choose the appropriate E/M code, if warranted, from the section for "office or other outpatient consultations." A pathologist would rarely perform an E/M more complex than 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) with an FNA.