What modifier is appropriate to indicate that two specimens were examined due to the first being inadequate for a fine needle aspiration (FNA) procedure?

Modifier for Repeat Fine Needle Aspiration Due to Inadequate Specimen

Modifier 76 is the appropriate modifier to indicate that two specimens were examined due to the first specimen being inadequate for a fine needle aspiration (FNA) procedure. 1

Rationale for Using Modifier 76

When a fine needle aspiration yields an inadequate specimen that cannot be used for diagnosis, and a second specimen must be obtained and examined to confirm a diagnosis, this represents a repeat procedure by the same provider. The clinical practice guidelines for evaluation of neck masses clearly distinguish between:

• An inadequate specimen - insufficient material for diagnosis
• An adequate but indeterminate specimen - sufficient material but inconclusive findings 1

In this scenario, the first specimen was specifically described as "inadequate to perform the test," which necessitated obtaining a new specimen. This situation calls for modifier 76 (repeat procedure by same physician).

Why Other Modifiers Are Not Appropriate

• Modifier 77 - This is used when a repeat procedure is performed by a different physician, which is not the case in this scenario.
• Modifier 91 - This is used for repeat laboratory tests, but FNA is a diagnostic procedure, not a laboratory test.
• Modifier C - This is not a standard modifier in the CPT coding system for this purpose.
• No modifier - This would be incorrect as it fails to indicate that the second procedure was necessary due to an inadequate initial specimen.

Clinical Context for Inadequate FNA Specimens

Inadequate specimens in FNA procedures are a recognized clinical issue:

• Studies show that inadequate specimens occur in approximately 9-20% of FNA procedures without on-site cytopathology evaluation 1
• The presence of an on-site cytopathologist significantly reduces inadequate samples (1% vs 12.6%) 1
• Following an FNA with inadequate results, a repeat FNA is recommended before resorting to more invasive procedures 1

Best Practices to Reduce Inadequate Specimens

To minimize the need for repeat procedures requiring modifier 76:

• Use ultrasound guidance for FNA, which has been shown to increase specimen adequacy 1
• When available, utilize on-site evaluation by a cytopathologist to reduce inadequacy rates 1
• For neck masses, consider core biopsy after an initial inadequate FNA, as it has a higher adequacy rate (95%) 1
• Use proper smearing techniques and rapid fixation of smears to improve specimen quality 2

Coding Implications

When billing for the repeat FNA procedure:

1. Use the same CPT code as the original procedure
2. Append modifier 76 to indicate the repeat procedure by the same physician
3. Document clearly in the medical record that the first specimen was inadequate, necessitating the second specimen collection

This approach ensures proper reimbursement while accurately reflecting the clinical circumstances that required the repeat procedure.