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2025 CPT code 88153

Cytopathology; cervical or vaginal slides; manual screening and rescreening under physician supervision.

Adhere to CPT guidelines and payer-specific requirements for coding cytopathology procedures.Proper documentation is essential to support medical necessity and correct code selection.

Modifiers may be applicable depending on the circumstances. Consult current CPT and payer guidelines.

Medical necessity is established based on clinical indications such as routine screening (e.g., annual well-woman exam), abnormal findings on prior testing, post-treatment surveillance, or investigation of symptoms (e.g., abnormal vaginal bleeding, discharge).

The clinical responsibility lies with the laboratory analyst performing the technical analysis under the supervision of a physician. The physician is responsible for interpreting any abnormal findings.

IMPORTANT:Other CPT codes may be applicable based on the method used (e.g., automated screening, specific preparation methods).HCPCS codes may be required for screening Pap tests by some payers (check payer specific guidelines).Professional interpretation of abnormal Pap smears is reported using separate codes (e.g., 88141).

In simple words: This lab test involves carefully looking at cells from a woman's cervix or vagina under a microscope, twice, to check for any problems. A lab technician does this test under a doctor's supervision. This is often part of a Pap smear.

This CPT code, 88153, represents the technical component of a cytopathology procedure involving manual screening and rescreening of cervical or vaginal slides.The procedure includes the complete microscopic analysis of the slides by a laboratory analyst under the supervision of a physician.The analyst performs the initial screening and then a second, confirmatory manual rescreening of the same slides. This is typically used for Pap smears but can apply to other cytology specimens from the cervix or vagina.The specimen itself is not a biopsy; rather, it consists of cells collected via swab or brush.

Example 1: A 25-year-old female presents for her annual well-woman exam, including a Pap smear. The laboratory uses manual screening and rescreening for the cytology analysis. Code 88153 is reported for the lab work., A 40-year-old female with abnormal vaginal bleeding undergoes a colposcopy, and a sample is collected for cytological examination.The lab performs a manual screening and rescreening; 88153 is reported., A 60-year-old female with a history of HPV infection has follow-up cytology. The lab utilizes manual screening and rescreening. The appropriate CPT code is 88153.

* Patient demographics* Date of service* Specimen type (cervical/vaginal)* Method of collection* Indication for testing* Microscopic report with interpretation (by physician)* Results

** Always verify with payer guidelines for specific requirements regarding coverage and coding of this test, including the use of HCPCS codes for screening tests in some cases.

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