Q. We received a thyroidectomy specimen. We also found a parathyroid gland with the specimen. We did a gross, micro, and rendered a diagnosis on it. Does this have to be bundled with the thyroid specimen, or can we bill for it?
A. You can report for the parathyroid gland in addition to the thyroid specimen because you came across it, identified it, performed a gross and micro, and rendered a diagnosis. It is not considered incidental. Although it is important for the surgeon to know if this gland was included for future hormones or treatments, it is not necessary to have the aid of the surgeon to identify it. You would report 88305 for this specimen.
Q. The pathology report says needle aspirate of a breast cyst. It is prepared at the lab using a thin layer preparation method. How would we code this exam?
A. With that information, you would report 88112 (cytopathology, selective cellular enhancement technique with interpretation). Aspiration of a breast cyst is a common procedure and has a specific CPT code [(19000) Puncture aspiration of cyst of breast]. Unless the documentation says it is an FNA and you get clarification that it truly is an FNA, you would report 88173 regardless of how the lab prepared the specimen.
"APS performed a comprehensive Coding Audit Review and subsequent financial impact assessment resulting in a significant increase in our revenue."