2025 CPT code 88141
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory - Cytopathology Procedures Pathology and Laboratory Feed
Physician interpretation of cervical or vaginal cytopathology specimen (e.g., Pap smear) using any reporting system.
Modifiers may be applicable depending on the circumstances of service.Consult official coding guidelines for specific modifier usage and payer guidelines.
Medical necessity for a cervical or vaginal cytopathology interpretation is typically established by the patient's age, risk factors (e.g., history of abnormal Pap smears, sexually transmitted infections, smoking), and guidelines from professional organizations (e.g., American College of Obstetricians and Gynecologists). Diagnostic interpretation is warranted when there are abnormal findings or clinical suspicion of cervical or vaginal disease.
The physician's responsibility is to analyze and interpret the cytopathology slide, identifying any cellular abnormalities that may suggest a pathological condition. This involves microscopic examination and application of relevant diagnostic criteria. The physician then prepares a report that summarizes the findings and provides a diagnosis (if any) using standardized terminology.
In simple words: This code covers a doctor's review of a Pap smear or similar test to check for cell abnormalities in the cervix or vagina. The doctor looks at the sample under a microscope and interprets the results. This is separate from the lab work done to prepare the sample.
This CPT code, 88141, encompasses the professional interpretation and analysis of a cervical or vaginal cytopathology specimen by a physician.The specimen, typically obtained via a Pap smear or liquid-based cytology, may be examined using various reporting systems, including but not limited to the Bethesda system. The code specifically covers the physician's interpretive work and does not include the technical aspects of specimen collection or preparation.It is billed separately from the technical component of the test.
Example 1: A 30-year-old female presents for a routine Pap smear. The cytology specimen is processed by the laboratory, and the resulting slides are sent to a pathologist for interpretation using the Bethesda system. Code 88141 is reported for the pathologist's interpretation of the slides in conjunction with the appropriate technical code for the Pap test performed in the laboratory., A 65-year-old female presents with post-menopausal bleeding. A vaginal and cervical specimen is obtained and sent for liquid-based cytology. The physician reviews the slides and notes atypical squamous cells of undetermined significance (ASC-US). Code 88141 is used to bill for the physician’s interpretation of the cytopathology test and results., A 25-year-old female undergoes colposcopy with directed biopsies. The biopsies and cervical scraping are processed for cytology review. The pathologist examines the slides microscopically and renders a report detailing both the cellular findings and the histologic findings. Code 88141 is used for the interpretation of the cytology, distinct from the interpretation of the biopsies which would use a separate pathology code.
* Patient demographics and medical record number.* Date of service.* Specimen type (cervical, vaginal, etc.).* Method of collection.* Test results, including microscopic findings and interpretation using a standardized reporting system (e.g., Bethesda).* Physician's signature and date of report.
** This code is for the physician's interpretation only.The technical component, including specimen collection and preparation, is billed separately using a distinct CPT code.Ensure correct coding to prevent claim denials.
- Revenue Code: T1G (LAB TESTS - OTHER)
- Payment Status: Active
- Modifier TC rule: This code represents the professional component; the technical component (TC) is billed separately.
- Specialties:Obstetrics and Gynecology, Pathology
- Place of Service:Office, Hospital, Clinical Laboratory