CANCER
319
CYTOPATHOLOGY
Immediate On-Site Interpretation of Fine-Needle
Aspiration Smears
A Cost and Compensation Analysis
Lester J. Layfield, M.D.
Joel S. Bentz, M.D.
Evelyn V. Gopez, M.D.
Department of Pathology, University of Utah School
of Medicine, Salt Lake City, Utah.
Address for reprints: Joel S. Bentz, M.D., Department of Pathology, University of Utah School of
Medicine, 50 North Medical Drive, Salt Lake City,
UT; Fax: (801) 585-3831.
Received December 13, 2000; revision received
March 16, 2001; accepted March 22, 2001.
© 2001 American Cancer Society
BACKGROUND. A significant body of literature exists supporting the cost effectiveness of fine-needle aspiration (FNA) cytology in the work-up of patients with
potential neoplastic disease. Several authorities have stated that immediate, onsite smear evaluation by cytopathologists optimizes diagnostic accuracy and minimizes the technique’s insufficiency rate. This favorable effect on FNA diagnostic
accuracy is most pronounced for deep body sites, where FNA is guided by computed tomography (CT), ultrasound, bronchoscopy, or endoscopy. Little data exist
regarding whether compensation from Medicare is adequate to support the pathologist in this endeavor compared with other potentially more remunerative
activities, including routine surgical pathology sign-out, nongynecologic cytopathology sign-out, and frozen section consultation.
METHODS. The authors studied a series of 142 fine-needle aspirates with immediate, on-site evaluations performed under a variety of clinical settings. These included bronchoscopic, endoscopic, ultrasound-guided, and CT-guided biopsies
along with palpation-directed biopsies performed by either cytopathologists or
clinicians. For these aspirates, total pathologist attendance time was calculated
and correlated with guidance technique, target organ, location where aspirate was
performed, and nature of aspirator. Fifty frozen section evaluations were timed
similarly. For comparison purposes, cytopathologists’ costs were calculated using
the 80th percentile pay level of an associate professor with full-time clinical duties.
Medicare rate schedules were used to calculate compensation. Including salary
and benefits, the pathologist cost was approximately $88.83 per hour.
RESULTS. On average, an intraprocedural FNA evaluation for a CT-guided biopsy
required 48.7 minutes, an ultrasound-guided biopsy required 44.4 minutes of
pathologist time, an endoscopic procedure required 56.2 minutes, a bronchoscopic
procedure required 55.3 minutes, a clinic aspirate performed by a pathologist
required 42.5 minutes, and a clinic FNA performed by a clinician required 34.7
minutes. The average frozen section required 15.7 minutes of pathologist time for
performance and interpretation. With the exception of FNA performed in clinic by
the cytopathologist, time costs exceeded compensation by $40 –50 per procedure.
Clinic aspirates performed by a clinician and immediately evaluated by a pathologist resulted in a deficit of approximately $18 over actual time cost.
CONCLUSIONS. From the current data, it appears that intraprocedural consultations
by cytopathologists for CT-guided, ultrasound-guided, bronchoscopic, or endoscopic procedures are compensated insufficiently by current Medicare compensation schedules using the CPT code 88172 for on-site evaluation. Only when the
cytopathologist personally performs the aspirate and immediately interprets it
(CPT codes 88172 and 88170) does the Medicare payment adequately compensate
for professional services. Cancer (Cancer Cytopathol) 2001;93:319 –322.
© 2001 American Cancer Society.
KEYWORDS: fine-needle aspiration, immediate interpretation, compensation, work
load.
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CANCER (CANCER CYTOPATHOLOGY) October 25, 2001 / Volume 93 / Number 5
F
ine-needle aspiration (FNA) is used widely as the
initial technique to obtain a tissue diagnosis in
patients suspected of harboring a neoplastic process.
FNA has been shown to be cost effective for the
work-up of patients with suspected neoplasms in a
wide variety of body sites, is considerably less expensive than alternate biopsy techniques, and it is associated with lower patient morbidity rates compared
with open biopsy.1–7 Authorities on FNA have stated
that immediate, on-site smear evaluation optimizes
the technique’s diagnostic accuracy by reducing the
rate of specimen inadequacy and aids in the timely
procurement of additional material for special studies
when needed.8,9 This beneficial effect is most prominent for FNA guided by computed tomography (CT),
ultrasound, or other imaging techniques, for which
the cost of repeating the study is relatively high.
Little data exist documenting the time expenditures
and costs associated with immediate, on-site smear evaluation and the associated prolonged attendance by cytopathologists at these procedures. Whereas some institutions have intraprocedural specimens prepared and
interpreted by cytotechnologists or brought to the cytopathology laboratory for cytopathologist review, other
institutions require on-site attendance by cytopathologists for smear preparation and interpretation. We studied the time commitments and costs associated with this
latter approach at a university hospital and its associated
clinics for FNAs performed at a variety of body sites
using a range of guidance techniques. We correlated the
cost of this time expenditure with Medicare compensation rates. In addition, comparison was made with time
expenditure and Medicare compensation for the comparable activity of frozen section preparation and evaluation.
MATERIALS AND METHODS
One hundred forty-two consecutive fine-needle aspirates requiring cytopathologist involvement during
the aspiration and immediate, on-site interpretations
were studied for time utilization. These aspirates were
obtained from a variety of body sites (Table 1) and
were guided by a variety of imaging techniques (Table
2). The majority were performed by radiologists or
clinicians, although a substantial minority were performed by cytopathologists (Table 2). All FNAs were
associated with on-site, immediate microscopic evaluation, resulting in assessment of adequacy and a
written preliminary cytologic diagnosis. Pathologist
time was measured in minutes from the time the
pathologist left the office to the time the pathologist
returned to the office after the aspiration procedure
and interpretation.
Fifty consecutive frozen sections were timed sim-
TABLE 1
Sites of Fine-Needle Aspiration in This Study
Site
No. of patients
Head and neck
Thyroid
Lung
Pancreas/biliary
Liver
Breast
Axillary lymph nodes
Bone/soft tissue
Skin
Chest
Retroperitoneal
Abdomen
Eye
Lymph node
Site not given
17
29
23
8
14
11
3
8
3
6
3
12
1
3
4
TABLE 2
Guidance Techniques Used in This Study for Fine-Needle Aspiration
Technique
No. of patients
Computerized tomography
Ultrasound
Endoscopy
Bronchoscopy
Intraoperative
Hospital room palpable
Clinic pathologist palpable
Clinician palpable
Outlying clinic
58
17
9
7
2
6
19
14
10
ilarly for comparison. Elapsed time for frozen section
was calculated as the time from arrival of the frozen
section specimen in the pathology laboratory to the
telephonic reporting of a diagnosis to the operating
room.
For ease of comparison, costs for pathologist involvement were calculated using the 80th percentile
salary level for an associate professor of pathology
published from national data.10 This salary was converted to an hourly rate using a full-time service commitment of 50 hours a week and 48 weeks per year. An
hourly cost of $88.83 per hour was calculated to include salary and associated benefits. The Medicare
rate schedule effective in Utah for the CPT codes
88170 ($65.16) and 88172 ($32.88) was used to calculate compensation.
Time studies for routine surgical pathology were
performed by measuring with a stop watch the actual
time required to evaluate the glass slides and dictate a
report for CPT codes 88305, 88307, and 88309. This
quantification was performed on 25 cases for each
CPT code with an average of four pathologists. Like
Cost Analysis of On-Site FNA Assistance/Layfield et al.
TABLE 3
Average Time Expenditure by Cytopathologist for On-Site FineNeedle Aspiration Evaluation by Guidance Technique
Guidance technique
Time expenditure (minutes)
Pathologist cost ($)
Computerized tomography
Ultrasound
Endoscopy
Bronchoscopy
Intraoperative
Hospital room palpable
Clinic pathologist palpable
Clinician palpable
Outlying clinic palpable
48.7
44.4
56.2
55.3
55.0
46.7
42.5
34.7
44.4
72.10
65.73
83.20
81.87
81.43
69.13
62.92
51.37
65.73
the cytology compensation estimates, the Medicare
rate schedule for CPT codes 88305 ($50.00), 88307
($92.75), and 88309 ($127.75) was used.
RESULTS
The average time expenditure by cytopathologists associated with each guidance technique and site are
given in Table 3 along with the associated cost for the
cytopathologist’s time. CT-guided biopsies required
approximately 49 minutes of cytopathologist time, ultrasound-guided biopsies required 44 minutes, endoscopic biopsies required 56 minutes, and bronchoscopic biopsies required 55 minutes. Aspiration of
palpable lesions performed by clinicians but immediately interpreted by a pathologist required an average
of 35 minutes of pathologist attendance. Aspirates of
palpable lesions performed and interpreted by cytopathologists required 42 minutes of pathologist time.
In contrast, the average frozen section required 16
minutes for performance and interpretation. The cost
of on-site cytologic interpretation generally exceeded
compensation by $40 –50 (Table 3). Only when pathologists personally performed the aspirates did compensation cover costs (Table 3). In comparison, compensation covered the total costs of frozen section
examination in this study.
On average, the professional time was 4.1 minutes
for an 88305 procedure, 7.7 minutes for an 88307
procedure, and 17.5 minutes for an 88309 procedure.
Hence, hourly compensation for signing out surgical
pathology cases with a mixture of 50% 88305, 20%
88307, and 30% 88309, was $638.
DISCUSSION
FNA has been proven as an accurate, cost-effective
technique for the diagnosis of patients with palpable
and nonpalpable lesions at a variety of body sites.1–7,10
FNA is most accurate when immediate assessment for
specimen adequacy is performed and a differential
321
diagnosis constructed so that additional material can
be acquired for special studies when needed.8,9 Although these studies have demonstrated the economies associated with the use of FNA over other biopsy
techniques, we are unaware of any studies evaluating
time expenditures by cytopathologists involved in immediate, on-site evaluation of smears obtained by
needle aspiration. The expenses to the pathology department associated with immediate, on-site interpretation and the associated prolonged attendance by
cytopathologists have not been estimated to our
knowledge.
Using an 80th percentile salary for an associate
professor of pathology ($88.83 per hour), we found
that the Medicare reimbursement rate (88172) for onsite evaluation undercompensated this activity by an
average of $40 –50 per patient. Only when the cytopathologist actually performed the aspirate and interpreted it in the clinic did Medicare compensation
(88172 and 88170) cover the costs of cytopathologists’
time expenditure.
Immediate consultation by pathologists is substantially undercompensated compared with routine
surgical pathology, for which a pathologist can generate approximately $638 per hour. Hence, from a purely
economic standpoint, a pathologist’s time is spent
better signing out surgical patients than performing
immediate, on-site evaluation of FNA specimens.
Medicare reimbursement for frozen section evaluation adequately covers cost expenditures for this service. From these data, it appears that academic pathology departments and private practice groups are
subsidizing immediate, on-site evaluation of FNAs by
approximately $40 –50 per patient. This untoward economic impact may lead cytopathologists to de-emphasize on-site evaluation or defer such services to cytotechnologists in an attempt to alleviate the unfavorable economic impact.
An alternative to the practice of immediate, onsite interpretation by pathologists is the use of cytotechnologists to screen patients and submit only difficult cases for pathologist review. Although this may
be appropriate in some institutions, it results in cytotechnologists rendering diagnoses of malignancy, albeit preliminary. At our institution, preliminary onsite assessments are similar to frozen section results,
in that therapeutic decisions may be enacted immediately based on these results. Hence, these diagnoses
require the review of a pathologist. At institutions
where therapeutic decisions are not based on immediate assessment but are delayed until final pathologist review, the use of cytotechnologists would appear
to be a reasonable alternative if sufficient cytotechnologists are available.
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CANCER (CANCER CYTOPATHOLOGY) October 25, 2001 / Volume 93 / Number 5
Preliminary, rapid, on-site diagnosis can be of
marked clinical importance, in that it assures the presence of diagnostic material, allowing invasive and potentially morbid procedures to be terminated as soon
as diagnostic material is obtained. This increases the
safety of the procedure as well as optimizing utilization of procedure rooms and imaging facilities. In
addition, it allows rapid institution of therapy in critically ill patients. Examples of conditions in which
immediate diagnosis and rapid initiation of therapy
may be critical include spinal cord compression by
lymphoma (treatable by radiation therapy) and lung
masses due to aggressive, infectious organisms.
Further studies are necessary to confirm these
findings. If subsequent studies support our data, then
Medicare compensation rates should be re-evaluated
and increased to provide adequate support for this
clinically valuable service. In addition, codes like
99358 for prolonged attendance may help alleviate the
negative economic impact on pathologists of prolonged attendance at image-guided FNAs.
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