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2025 CPT code 88112

This CPT code represents the selective cellular enhancement for cytopathology using liquid-based slide preparation, excluding cervical or vaginal specimens.

Adhere to CPT coding guidelines for cytopathology and liquid-based preparations.Ensure the exclusion criteria (cervical and vaginal specimens) are carefully observed.

Modifiers 26 (professional component) and TC (technical component) may apply depending on whether the physician performed the professional component only or the entire procedure.

The medical necessity for this procedure is established based on the need for cytological evaluation of non-cervical and non-vaginal specimens to determine the presence of disease (e.g., malignancy, infection, or inflammatory process).The physician should document the clinical findings that justify the need for the procedure.

The clinical responsibility involves specimen collection (using a broom-type device or spatula and brush), proper storage and preservation of the sample using liquid-based medium, and sending the specimen to a pathology laboratory for examination.

IMPORTANT:For cytopathology procedures not specified in codes 88104-88189, code 88199 (unlisted cytopathology procedure) may be used.

In simple words: This medical code covers a special way of preparing tissue samples for microscopic examination in a lab. It uses a liquid to collect and preserve the cells, making it easier and more accurate to analyze them under a microscope.This method is not used for samples from the cervix or vagina.

CPT code 88112 describes the performance of selective cellular enhancement for cytopathology utilizing a liquid-based slide preparation method.This technique involves collecting samples and preserving cells within a liquid-based medium. The process aids in improved sampling, reduces collection errors, and offers advantages such as easier slide review, immediate liquid fixation, cleaner background, a faster detection rate, and the ability to process residual material as a cell block.This code specifically excludes cervical and vaginal specimens.

Example 1: A patient presents with a suspicious lesion on their skin. A sample is collected using a brush and processed using liquid-based cytology for analysis, to look for malignant cells.Code 88112 is used to bill for this procedure., Fine needle aspiration (FNA) is performed on a palpable breast mass. The aspirate is processed using liquid-based cytology. This process is billed using 88112., A patient has a suspicious lymph node that requires biopsy.A sample is collected and prepared using liquid-based cytology for pathology review.88112 is appropriately used in this scenario.

* Detailed clinical indication for the procedure.* Specimen collection method and site.* Confirmation that the specimen is not from the cervix or vagina.* Pathology report with microscopic description and interpretation.* Supporting medical records indicating medical necessity.

** Always refer to the most current CPT codebook and payer guidelines for accurate coding and reimbursement.Ensure that the documentation supports medical necessity and properly reflects the procedure performed.

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