Editor: Frederick L. Kiechle, MD, PhD
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Q. Ordering clinicians are requesting that our laboratory flag abnormally high absolute neutrophil counts (ANC) on peritoneal fluids. We cannot find sources for reference ranges, but there is literature that states that a polymorphonuclear cell count greater than 250/μL is a reliable discriminatory test for bacterial peritonitis. We would like to use this as our reference and flag results with an ANC greater than 250 cells/μL as abnormally high. Is this acceptable?
A.April 2024—Numerous guidelines agree that the diagnosis of spontaneous bacterial peritonitis should be based on an ANC greater than 250 cells/μL in peritoneal fluid from a patient with ascites. This ANC result is sufficient cause for initiating empirical antibiotic therapy. This is because patients with spontaneous bacterial peritonitis usually do not display the typical signs and symptoms of infection, such as fever, abdominal pain, and an elevated white blood cell count on a CBC. It is more likely that these patients will present with encephalopathy, decreasing renal function, or gastrointestinal bleeding or will be asymptomatic.
It is important that the laboratory notify the clinical care teams of an ANC result greater than 250 cells/μL found while performing a diagnostic paracentesis to diagnose spontaneous bacterial peritonitis. At a minimum, the findings should be flagged as abnormally high in the lab report. This will give patient care teams the best chance of starting antibiotic therapy before the patient becomes septic or goes into septic shock.
Aithal GP, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021;70(1):9–29.
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014–1048.
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53(3):397–417.
Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA. 2008;299(10):1166–1178.
Timothy Skelton, MD, PhD
Medical Director, Core Laboratory and Clinical Informatics
Lahey Hospital and Medical Center
Medical Director
Laboratory and Pathology Informatics
Beth Israel Lahey Health
Former Member, CAP Hematology/Clinical Microscopy Committee
Q. How do you code fallopian tubes submitted for sterilization with a finding of a paratubal cyst?
A.Current Procedural Terminology (CPT) billing codes are determined based on the average level of effort involved in analyzing a tissue sample. This estimation considers three key variables: physician work, practice expense, and liability insurance factors.1 Physician work encompasses skill, judgment, and time, which are influenced by factors such as the patient’s medical history, purpose of the procedure, and pathologist’s final diagnosis.
The CPT code for fallopian tube sterilization is 88302. If the surgeon designates each fallopian tube separately, each is assigned its own 88302 code. Incidental paratubal cysts in salpingectomy specimens are common. In a 2020 study, these cysts were found in 42 percent of fallopian tubes that were evaluated using the SEE-FIM (sectioning and extensively examining the fimbriated end) technique.2 The cysts are usually less than a centimeter in size, and there is no consensus among pathologists on whether they require microscopic evaluation or mention in the report.3
In the majority of cases, there is no clinical indication for removing paratubal cysts as part of the sterilization procedure. The primary intent of the surgery is sterilization, and the diagnosis of a paratubal cyst does not influence how the patient is subsequently managed. Therefore, it would be unwise to artificially elevate the coding for sterilization samples by treating these incidental and clinically insignificant findings as a separate billable unit.
However, when a sterilization sample is submitted with a specific request by the surgeon to evaluate the paratubal cyst (for example, the specimen is labeled fallopian tube and cyst), an additional charge of 88304 level three for the cyst is reasonable.
- CPT, RBRVS, RUC: a primer on the alphabet soup of coding and reimbursement. J Oncol Pract. 2007;3(1):20–22.
- Sunde J, Wasickanin M, Katz TA, Wickersham EL, Steed DOE, Simper N. Prevalence of endosalpingiosis and other benign gynecologic lesions. PLoS One. 2020;15(5):e0232487.
- Zheng R, Heller DS. A comprehensive review of paratubal lesions. Ann Diagn Pathol. 2022;57:151877.
Vinita Parkash, MBBS, MPH
Associate Professor of Pathology
Yale University School of Medicine
New Haven, Conn.
Vice Chair, CAP Surgical Pathology Committee