2025 CPT code 88160
(Active) Effective Date: N/A Pathology and Laboratory Procedures - Cytopathology Pathology and Laboratory Feed
Cytopathology, smears, any other source; screening and interpretation. This code is used for the microscopic examination of cells from sources other than fluids, washings, brushings, or gynecological specimens.
Modifiers may be applicable to this code to indicate specific circumstances, such as the professional component (26), distinct procedural services (59), or reference laboratory services (90).
Medical necessity must be established for this procedure. Documentation should support the reason the test was ordered and how the results will impact the patient's treatment plan.The medical record should clearly indicate the signs, symptoms, or other clinical findings that justify the need for cytopathologic examination.
The laboratory professional performs the technical aspects of the procedure, including preparing, screening, and interpreting the slides. The clinician obtains the specimen.
In simple words: This test involves examining cells under a microscope from a sample that isn't a fluid or a gynecological sample. The lab technician looks at the cells to see if they are normal or not.
This procedure involves the examination of a smear of cells obtained from a source other than fluids, washings, brushings, or the cervix or vagina. The pathologist screens the slide for abnormal cells and then interprets any abnormalities found. The service includes both the screening and interpretation of the smear.It's important to select the appropriate code based on the source of the specimen. For example, if the specimen is derived from fluids, washings, or brushings, code 88104 should be used instead. If a concentration technique or selective cellular enhancement technique is used, codes 88108 or 88112 should be reported, respectively.
Example 1: A patient presents with a persistent cough. The physician orders a sputum smear to be examined for abnormal cells, including malignant cells. The lab receives the sputum sample and prepares the slide for microscopic examination. The cytopathologist screens the slide and interprets the findings, using 88160., A patient has a suspicious nipple discharge. A smear of the discharge is prepared and sent to the lab for cytopathologic examination. The cytopathologist examines the smear and reports the findings. Since this is not a fluid, washing, or brushing, and not of gynecological origin, code 88160 is reported. , A patient has a skin lesion biopsied. A touch prep smear is created at the time of biopsy and sent to pathology for immediate review for cancer. The cytopathologist screens the smear and interprets the findings. Since this is a smear from another source, 88160 is the appropriate code.
Documentation should include the source of the specimen, the reason for the test, the preparation method (if any), the cytopathologist's findings, and the interpretation of the findings. It should also indicate if any special stains or extended studies were performed.
** As of December 1st, 2024, code 0832T can be used in conjunction with 88160 for the digitization of glass microscope slides.
- Specialties:Pathology, Oncology, Pulmonology, Dermatology, General Surgery
- Place of Service:Independent Laboratory, Office, Outpatient Hospital, Inpatient Hospital, and other places where pathology services are provided.