Coding Question - Thyroid FNA / 88172, 88177
30 June 2011
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Our radiologist performed a thyroid FNA and sent slides from three passes for immediate evaluation by the pathologist. Is this coded 88172, 88177 x 2?
It depends on how the radiologist submitted the three passes for immediate evaluation and how the pathologist documented his/her services. The 88172 and 88177 codes were updated in 2011, and are now reported per evaluation episode.
88172: Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
88177: Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)
Your inquiry does not indicate how the radiologist submitted the three passes. If all three passes were submitted for the pathologist to evaluate during a single episode, only a single unit of 88172 would be reported. However, if passes were sequentially submitted and the pathologist reviewed and provided a determination of adequacy before the next pass was submitted for evaluation, it would be appropriate to code separately for each evaluation. If this is the case, the 88172 code would be reported for the initial immediate evaluation, and two units of 88177 for the two subsequent immediate evaluations.
Report documentation plays a vital role in the code selection; therefore, it is important that each evaluation episode is clearly documented.
Capture the charge for the final examination and diagnosis of the aspirate smears by assigning the 88173 code (Cytopathology, evaluation of fine needle aspirate; interpretation and report). Ancillary services, such as a cell block or special stains should also be reported when performed and appropriately documented.
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