Carol A. Filomena MD, Anupama K. Sharma MD and Swati Mehrotra MD

Mr. Lang, a 77 year-old male with recently diagnosed lung adenocarcinoma, presents with a sacral mass. The oncologist requests tissue procurement for diagnosis and next generation sequencing (NGS) ancillary studies. The onsite cytopathologist receives 2 fine needle aspiration biopsies (FNAs) and 2 needle core biopsies (NCBs) of the sacral mass from the interventional radiologist with a request for rapid interpretation. The cytotechnologist prepares an air-dried direct smear and an alcohol-fixed direct smear from each FNA and rinses the residual contents from both needles into RPMI. She prepares two air-dried touch preparation slides (one from each tissue core) from the NCBs and notes difficulty due to the presence of focal calcification of each core. The residual cores are placed together into a vial of formalin. Each air-dried direct smear and each touch preparation slide is reviewed onsite by the cytopathologist.

RAPID INTERPRETATION:

 Bone (Sacral Mass), Fine Needle Aspiration Biopsy:
Passes 1-2: Rare malignant cells.

 

Bone (Sacral Mass), Needle Core Biopsy:
Core 1: Rare malignant cells.
Core 2: Rare malignant cells.

Celine Cell, MD

Based on the rapid interpretations, the cytopathologist asks the radiologist to obtain two additional needle cores and places them into the formalin container with the residual cores.

The slides and specimens are transported to the laboratory. The needle rinses in RPMI from the FNAs are transferred into formalin and processed as a cell block. The needle cores (two residual and two intact) are examined and the presence of calcification is observed. The clinician’s order for NGS testing is noted. The calcified portions are separated from soft portions of the cores. The hard tissues are submitted in block A1 for formalin fixation with decalcification. The residual softer tissue is submitted in block A2 for formalin fixation without decalcification. Upon slide review, the pathologist requests immunohistochemical tests for cytokeratin 7, thyroid transcription factor, napsin A and cytokeratin 5/6.

 

FINAL INTERPRETATION(S):

 

Bone (Sacral Mass), Fine Needle Aspiration Biopsy:
Positive for malignant cells.
Adenocarcinoma with features consistent with metastatic adenocarcinoma of primary lung origin.
See note.

Note: The diagnosis is based upon evaluation of direct smears and a cell block. Please refer to the needle core biopsy report for additional information including immunohistochemical analysis.

 

Bone (Sacral Mass) Needle Core Biopsy:
Positive for malignant cells.
Adenocarcinoma with features consistent with metastatic adenocarcinoma of primary lung origin.
See note.

 Note: Immunoperoxidase stains were performed on formalin-fixed non-decalcified tissue in block A2 with appropriate controls. The tumor cells stain with CYTOKERATIN 7, THYROID TRANSCRIPTION FACTOR and NAPSIN A and do not stain with CYTOKERATIN 5/6. These findings are in support of the interpretation of metastatic adenocarcinoma with features consistent with primary lung origin.

 The diagnosis is based upon evaluation of touch preparation slides and tissue sections from blocks A1 and A2. Block A2 will be submitted for NGS testing and a separate report will be issued.

Celine Cell, MD

 

How would you code this complex but rather typical scenario?

This scenario highlights the importance of clear communication within the laboratory. The person or persons present onsite in the radiology suite must ensure a consistent method of communication to those involved in subsequent specimen preparation and interpretation. The clinical request for ancillary testing, the physical nature of the specimen and the presence of two separate specimens (FNA and NCB) must be communicated to all involved, especially when duties are transferred to other technologists and/or pathologists or when the specimen is divided and processed by separate laboratory sections. The number and types of codes will be the same regardless of whether the diagnoses appear on the same or separate final reports.

 

ANSWERS:

Coding the Fine Needle Aspiration Biopsy: 88172, 88173, 88305

88172: Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site

Note: Slides from both needle passes were reviewed together and one rapid interpretation was issued by a cytopathologist to yield code 88172. If additional FNA passes were performed and interpreted in the setting of an initial “nondiagnostic” interpretation, the code 88177 would be added for each additional rapid interpretation.

88177 – Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate evaluation episode, same site

 

88173: Cytopathology, evaluation of fine needle aspirate; interpretation and report

88305: Level IV – Surgical pathology, gross and microscopic examination, cell-block, any source

 

Coding the Needle Core Biopsy: 88333, 88334, 88307, 88311, 88342, 88341 x 3

88333: Pathology consultation during surgery; cytologic examination (e.g. touch prep, squash prep), initial site

88334: cytologic examination (e.g. touch prep, squash prep), additional site

88307: Level V – Surgical pathology, gross and microscopic examination

88311: Decalcification procedure (List separately in addition to code for surgical pathology examination)

88342: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

88341: each additional single antibody stain procedure (List separately in addition to code for primary procedure)

Note: Since a rapid interpretation was performed on each of two tissue cores, code 88334 is utilized for interpretation of the second NCB. Code 88307 is utilized (rather than 88305) since the core biopsy is of bone. Code 88311 is added since the specimen required decalcification (applied once per specimen). Code 88342 is utilized for the first immunohistochemical stain and code 88341 is applied for each additional immunohistochemical stain. (If the amount of non-decalcified tissue is limited, the immunohistochemical evaluation may be performed on the decalcified tissue block.) If a multiplex antibody immunohistochemical stain is utilized code 88344 would be applied.

88344: Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure