Pathology/Lab Coding Alert

Question: Please help with coding for the following scenario: three slides from pelvic wash consisting of cloudy yellow/pink fluid. Prep cell block and examine slides with H&E stain. Should we code only cytology, and is there a separate code for the stain?


Colorado Subscriber


Answer: You should code the cytology from the three slides prepared directly from the pelvic washing as 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation). You report the code only once regardless of the number of slides.

But the cell block constitutes a separate service, so you should report an additional 88305 (Level IV - Surgical pathology, gross and microscopic examination, cell block, any source). You should not list a separate code for a hematoxylin and eosin (H&E) stain, because it is a standard staining technique.

You can only report special stain codes such as +88312 (Special stains [list separately in addition to code for primary service]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) for stains that you perform in addition to the standard stains such as H&E. Reader Questions and You Be the Coder were prepared with the assistance of R. M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.