Pathology/Lab Coding Alert

Question: When we prepare six or more slides from a fine needle aspiration specimen or other cytology such as CSF direct smears, can we report 88162?

Arizona Subscriber

Answer: No, you should not use 88162 (Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains) for fine needle aspiration (FNA) specimens or fluid specimens, such as cerebral spinal fluid (CSF), regardless of the number of slides that your prepare.

Here's why: The CPT cytopathology section describes different cellular specimen types based on the source, as follows:

• non-cervical or vaginal fluids, washings or brushings (88104-88112)

• cervical or vaginal (88142-88154, 88164-88167, 88174-88175)

• any other source (88160-88162) including specimens, such as sputum and nipple smears

• FNA (88172-88173).

You select the appropriate cytopathology code by first identifying the specimen source, then identifying the lab method for that source. Using 88162 for an FNA with more than five slides amounts to "switching sources," which you can't do.

Define "other": Codes 88160-88162 (Cytopathology, smears, any other source ...) refer to any source besides the other cytopathology sources in CPT. In other words, 88160-88162 describe specimens that are not cervical or vaginal, not fluids, washings or brushings, and not FNAs. Regardless of the number of slides your lab prepares and examines from a particular source, you must report a single unit of the code that most closely describes the cytopathology source and lab method.