2025 CPT code 88104
(Active) Effective Date: N/A Pathology and Laboratory Procedures - Cytopathology Procedures Feed
Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation.
Modifiers such as 26 (Professional Component), 59 (Distinct Procedural Service), 90 (Reference [Outside] Laboratory), and 91 (Repeat Clinical Diagnostic Laboratory Test) may be applicable depending on the circumstances of the service.
Medical necessity is established by the clinical indication for the test, such as suspicion of infection, inflammation, or malignancy. The documentation must support the need for the procedure to evaluate the patient's condition.
The pathologist receives the specimen, prepares and stains the slide, performs microscopic examination, interprets the findings, and generates a report, including possible diagnoses or recommendations for additional testing.
In simple words: This procedure involves examining cells from body fluids (except cervical or vaginal fluids) under a microscope to detect abnormalities. A small sample of fluid is spread on a slide, treated, and stained to make the cells easier to see.A pathologist then examines the slide and provides a report.
This code encompasses the examination of fluids, washings, or brushings, excluding those from the cervix or vagina, using smear preparation and microscopic interpretation by a pathologist to identify cellular changes indicative of disease processes such as cancer, infection, or inflammation. The procedure includes receiving a liquid specimen (e.g., bronchial washings, cerebrospinal fluid, pericardial fluid), preparing a smear on a microscope slide, treating it chemically or air drying it, applying stains, conducting a microscopic examination, and interpreting the findings to provide a diagnosis or recommend further testing.
Example 1: A patient with suspected pneumonia undergoes bronchoscopy, and the bronchial washings are sent for cytopathology examination (88104) to identify infectious organisms or abnormal cells., A patient presents with a pleural effusion. A sample of pleural fluid is sent for cytopathology (88104) to evaluate for the presence of cancer cells, infection, or other inflammatory conditions., A patient with a suspected pericardial effusion undergoes pericardiocentesis. The pericardial fluid is sent for cytopathologic examination (88104) to assess for infection, inflammation, or malignancy.
Documentation should include the type and source of the fluid, washings, or brushings; the clinical indication for the test; the preparation method; the pathologist’s microscopic findings; and the interpretation and diagnosis or recommendations.
** As of December 1st, 2024, the information provided is current.However, medical coding guidelines and regulations can change. It is essential to refer to the latest coding manuals and payer guidelines for up-to-date information. For digitized slides add-on code 0827T is used.
- Revenue Code: T1G - LAB TESTS - OTHER (MEDICARE FEE SCHEDULE)
- Specialties:Pathology
- Place of Service:Independent Laboratory, Hospital (Inpatient or Outpatient)