This commentary is a summary prepared by McKesson’s Revenue Management Solutions division and highlights certain changes, but not all changes, in 2011 CPT® codes relating to the specialty of anesthesiology. This commentary does not supplant the American Medical Association’s (AMA) current listing of CPT codes, its documentation in the annual CPT Changes publications and other related publications from the AMA, which is the authoritative source for information about CPT codes. Please refer to your 2011 CPT Code Book, annual CPT Changes publications, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document. CPT is a registered trademark of the American Medical Association (AMA). The AMA is the owner of all copyright, trademark and other rights to CPT and its updates.

Fine Needle Aspiration

Question:

The pathology department received four slides from four passes for immediate evaluation from a right thyroid fine needle aspiration (FNA) performed in the radiology department by one of the radiologists. Should this be coded as 88172, 88177 x3?

 

Answer:

CPT® codes 88172 and 88177 were updated January 2011 and now include the verbiage “evaluation episode” as the standard to establish unit of service. The CPT manual defines both the evaluation episode and repeat immediate evaluation episode(s):

  1. An evaluation episode is defined as a complete set of cytologic material submitted for evaluation and is independent of the number of needle passes or slides prepared. A separate evaluation episode occurs if the proceduralist provider (physician that actually performed the collection procedure) obtains additional material from the same site, based on the prior immediate adequacy assessment, or a separate lesion is aspirated.
  2. A repeat immediate evaluation episode(s) is defined as requiring subsequent cytologic material from the same site (e.g., following determination of the prior sampling that was not adequate for diagnosis). It would be assigned one unit of 88177 for each additional evaluation episode.

Simply put, if the first pass done by the provider collecting the sample was sent to the pathologist to determine the adequacy of the specimen and that adequacy was not sufficient, the pathologist would report inadequate specimen. In addition, the provider collecting the sample would proceed to obtain another specimen, send it down to the pathologist for adequacy assessment and so forth. Each separate submission of a sample for evaluation episode adequacy check would equal a unit of service. The first unit of service is assigned CPT 88172; any additional evaluation episodes performed on the same lesion site would be assigned CPT 88177.

 

The answer to the above scenario as it is presented would be 88172 x1 because it does not describe how the radiologist submitted the passes. In order for the documentation to support billing the additional units of 88177, the pathologist’s report must clearly document:

  1. That the specimens were received by the pathologist at different intervals for evaluation, and
  2. In order to meet medical necessity the preceding sample sent was not adequate for further analysis.

Using a time stamp or similar method for each of the separate sample(s) (i.e., passes) sent to the pathologist for analysis would meet the requirement.

 

Documentation is key! If it is not documented, it is not done.

 

Reference: CPT 2011 Manual

 

Kimberly J. West, CPC
Compliance – Pathology
McKesson Revenue Management Solutions

 

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