Date of Service: 10-1-15
Clinical History:69 year old Medicare patient presenting with a nodule in the left thyroid.
The radiologist performs a CT-guided fine needle aspiration (FNA), on a nodule identified on the left thyroid. After each needle pass, the pathologist performs immediate adequacy evaluation assessment, and documents each separate evaluation episode as the radiologist is guided to a diagnostic specimen, and provides to the radiologist the adequacy of that specimen as follows:
- Pass 1 - blood only
- Pass 2 - blood only
- Pass 3 - adequate for evaluation
- Pass 4 - adequate for evaluation
Additional fixed aspirate slides are received for routine processing and evaluation.
Final Diagnosis: Lymphocytic thyroiditis
What are the appropriate CPT and ICD-10 codes for this scenario?
|FNA – Nodule|
|E06.3 – Lymphocytic thyroiditis|
|88172 ||Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site |
|88173||Cytopathology, evaluation of fine needle aspirate; interpretation and report |
|+88177||Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site |
Correct CPT coding for this FNA scenario is 88173 (FNA interpretation and report), 88172 (initial evaluation episode to assess specimen adequacy), and 88177 x2 (each additional evaluation episodes until an adequate specimen was obtained).
The parenthetical statement listed beneath the CPT code descriptor for 88173 directs the coder to assign one unit of 88173 for the interpretation and report from each anatomic site, regardless of the number of passes or evaluation episodes performed during the aspiration procedure. Documentation of immediate adequacy episode results is required in order to bill the 88172 and the add-on 88177 codes, and was appropriately documented in this scenario. The pathologist performed a separate evaluation episode on four different passes; however, since the third pass produced an adequate specimen, pass number four is not coded.
As indicated in this FNA scenario, it is important to review the parenthetical statements listed below the 88173, 88172, and 88177 code descriptors, which provide additional information that is critical to accurate CPT coding assignment.
ICD10-CM Code Descriptors and Breakdown:
Final Diagnosis of Lymphocytic thyroiditis
E06.3 Autoimmune thyroiditis (lymphocytic thyroiditis)
Alpha Index: Thyroiditis – lymphocytic E06.3. The four character code is broken down as follows:
- E06 is the primary descriptor for Thyroiditis
- 4th digit of "3" defines the type of thyroiditis as autoimmune, and lymphocytic thyroiditis is included under this heading