2025 CPT code 88161
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Cytopathology Procedures Pathology and Laboratory Feed
Cytopathology smear preparation, screening, and interpretation from any source other than those specified in more specific CPT codes.
Modifiers may be applicable depending on the circumstances of service (e.g., 26 for professional component, TC for technical component, etc.). Refer to the CPT manual for modifier usage guidelines.
Medical necessity is established by the physician's clinical judgment based on the patient's symptoms, clinical presentation, and relevant risk factors.Documentation should justify the need for cytopathological evaluation.
Laboratory personnel perform the technical component (preparation, screening, and interpretation). Clinicians are responsible for ordering the test and interpreting the results in the context of the patient's overall clinical picture.
- Pathology and Laboratory
- 88160 family of codes.Used when a more specific code for cytopathology smears is unavailable.
In simple words: This lab test involves preparing a sample of cells (smear), examining it under a microscope to look for abnormalities, and interpreting the results to help diagnose medical conditions. It's used for cell samples that aren't covered by more specific tests.
This CPT code, 88161, encompasses the preparation, screening, and interpretation of cytopathology smears from sources not detailed in more specific codes (e.g., 88104-88189).The procedure includes the technical steps of preparing the smear (staining or fixation), microscopically screening for cellular abnormalities, and interpreting findings. This code is applicable when the specimen is a smear obtained via swab or similar method, not from fluids, washings, or brushings.The analysis might involve assessment for malignancy, radiation or chemical damage, or other cellular abnormalities.If the slide is not prepared by the lab analyst, use code 88160.
Example 1: A patient presents with a persistent cough.The physician orders a sputum smear to assess for malignant cells or other abnormalities.The laboratory technician prepares the smear, screens for cellular abnormalities, and provides an interpretation. Code 88161 is used., A patient undergoes a breast exam, and the physician performs a fine-needle aspiration biopsy. Although a fine-needle aspirate may sound similar to a smear, a distinct code is used for the microscopic examination of a fine-needle aspirate.However, if a smear is prepared from the aspirate sample, 88161 could be used in addition to the fine needle aspirate code, depending on the circumstances and payer guidelines., A patient presents with nipple discharge. A smear is prepared from the discharge. The lab performs the preparation, screening, and interpretation of the smear. Code 88161 is appropriate.
Patient demographics, date of service, specimen source, microscopic findings, interpretation, and any relevant clinical information.Physician order specifying the test. Lab report with detailed findings.
** This code should be used cautiously and only when no other more specific code applies.Always verify payer specific guidelines and local coverage determinations.
- Revenue Code: T1G (LAB TESTS - OTHER)
- RVU: Information not provided.Refer to CMS guidelines and local payer policies for current RVU values.
- Global Days: Not applicable.
- Payment Status: Active
- Modifier TC rule: The TC modifier may be used to indicate that only the technical component was performed if applicable. Consult payer guidelines.
- Fee Schedule: Information not provided.Refer to historical CPT fee schedules and local payer data for historical fee information.
- Specialties:Pathology, Cytology, Oncology, Pulmonology (depending on specimen source)
- Place of Service:Laboratory, Hospital (Inpatient/Outpatient), Physician's Office