2025 CPT code 88167
(Active) Effective Date: N/A Pathology and Laboratory - Cytopathology Screening Procedures Pathology and Laboratory Feed
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision.
Modifiers may be applicable depending on the specific circumstances of the service. For example, modifier 90 is used if the test is performed by a reference (outside) laboratory.
Medical necessity is determined by the patient's symptoms, risk factors, and/or the findings of the initial manual screening that justify further analysis with computer-assisted rescreening.
The laboratory analyst performs the technical aspects of the test, including manual screening and computer-assisted rescreening. A physician supervises the process and interprets the results.
In simple words: This test involves a lab technician examining cells from the cervix or vagina under a microscope, first manually and then using a computer to help identify specific cell types. The results are reported using a standardized system called the Bethesda System.
This code represents the analysis of cervical or vaginal cytology slides using a two-step process. First, a trained analyst manually screens the slide under a physician's supervision. Then, the same slide is rescreened with computer-assisted technology that uses cell selection and review algorithms. The Bethesda System is used for reporting the results.
Example 1: A patient undergoes a routine Pap smear as part of an annual exam. The initial manual screening reveals some atypical cells, prompting a computer-assisted rescreening for further analysis using 88167., A patient experiences vaginal discharge and undergoes a Pap smear.The manual screening is inconclusive, so the slide is rescreened using computer assistance and cell selection to clarify the findings, reported using the Bethesda system, billed as 88167., A patient with a family history of cervical cancer undergoes a routine screening Pap smear. The initial manual review suggests some abnormalities. The sample is then rescreened using computer-assisted technology, focusing on specific cell characteristics to determine if further investigation is needed and billed under 88167.
Documentation should include the initial manual screening results, the reason for the computer-assisted rescreening, the findings of the rescreening, and the Bethesda System report.
** If a physician interprets an abnormal Pap, code 88141 should be reported for the professional interpretation.For collection of specimen via fine needle aspiration biopsy, see codes 10004-10012, 10021.
- Revenue Code: T1H
- Specialties:Pathology, Obstetrics and Gynecology, Family Medicine
- Place of Service:Independent Laboratory, Office