Wiki Fna adequacy

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Please help with thyroid, fine needle aspiration coding.
Gross description: Rec. 2 prepared smear slides and 20 cc of brownish-red bloody fluid in preservcyt container frm which 2 cytospins are prepared and the 4 slides are stained w/papnicolaou and giemsa stains.
Specimen was diluited 6:1 in cytolyt solution.

Pathology procedures: Tissue adequacy, fna process.

Do i code 88172 adequacy and 88173 fna interp?
 
You need an documented interpretation in order to code for evaluating adequacy. it is either adequate, inadequate, or undetermined. Any option is acceptable. The presence of documented results proves medical necessity and that a service was actually provided.

The code describes both a technical and professional component. You've provided the technical component. If no one has looked at it and rendered a professional opinion, it is processing done for no reason.

I hope you've got more in the report than this, such as a dx. I wouldn't even code 88173 with what is provided and expect to defend it in an audit.

Best,
WK
www.whaleheadking.com
 
thanks for your response. Gave me the information I needed to take back to Pathologist for clarification of reports.
 
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