CPT Coding Corner

We performed a frozen section and touch prep on a brain tumor specimen.  Are the correct codes 88331 and 88334?

Yes. However, you can only report 88331 (Pathology consultation during surgery; first tissue block) and 88334 (......cytologoic examination (touch prep, squash prep) additional site) if there is documentation to support that the frozen section and touch prep performed are done on the same specimen and on separate sites.  Documentation must support that the frozen section and touch prep evaluations are performed on a different site when done on the same specimen. 

If the documentation would support different sites, codes 88331 and 88334 can be reported.

Would I report 88173 for fluid from a cyst aspirate?

Yes. You can if the surgical procedure is CPT code 10021 (FNA; without imaging) or 10022 (FNA; with imaging).  If the surgical procedure is, for example, CPT code 19000 (Puncture aspirate of cyst of breast), 10160 (Puncture aspiration of abscess, hematoma, bulla or cyst) or other similar codes for specific locations, then report cytology codes for the method of preparation, 88104, 88108 or 88112.

It is very important to know the surgical procedure for this type of specimen, as it will help you choose the correct CPT code for the work performed.  It is important to always document appropriately to support your code selection.