2025 CPT code 88164
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Cytopathology Procedures Pathology and Laboratory Feed
Manual screening of cervical or vaginal cytopathology slides using the Bethesda System under physician supervision.
Modifiers may be applicable depending on the circumstances.Refer to current CPT guidelines and payer-specific instructions for appropriate modifier use. This might include modifiers for multiple specimens or different places of service.
Medical necessity for a Pap smear depends on the patient's age, risk factors (sexual history, family history of cervical cancer, prior abnormal Pap smears), and presenting symptoms. Screening Pap smears are recommended for specific age groups and those with risk factors, while diagnostic Pap smears are indicated for abnormal physical findings or symptoms suggestive of cervical disease. Appropriate ICD-10 codes should be used to support medical necessity.
The clinical responsibility lies primarily with the cytotechnologist/laboratory analyst for performing the technical aspects of the test (microscopic examination and interpretation under physician supervision) and reporting the results. The physician is responsible for ordering the test, interpreting the results in context with the patient's clinical presentation, and managing the patient's care based on the findings.
In simple words: This medical code covers the lab work involved in examining a Pap smear under a microscope. A trained technician looks at the sample for any abnormal cells that might indicate disease, using a standard reporting system. The doctor reviews the results.
This CPT code, 88164, represents the manual microscopic examination and interpretation of a cervical or vaginal cytopathology specimen (most commonly a Pap smear) utilizing the Bethesda System.The procedure involves a cytotechnologist or laboratory analyst, under the direction of a physician, manually screening the prepared slide for cellular abnormalities.The Bethesda System is a standardized reporting method that includes an assessment of specimen adequacy and a categorization of any cellular findings, ranging from negative for malignancy to various degrees of precancerous or cancerous changes. The service does not include the collection of the specimen or any ancillary testing.
Example 1: A 25-year-old female presents for her annual well-woman exam.A routine Pap smear is collected. The cytology lab uses the Bethesda system and manual screening methods to process the smear. Code 88164 is reported., A 40-year-old female with a history of abnormal Pap smears presents for follow-up.A Pap smear is collected. Code 88164 is reported, as the lab processes it manually utilizing the Bethesda system., A 60-year-old female presents with vaginal bleeding.A diagnostic Pap smear is collected. The lab uses the Bethesda system and manual screening, and code 88164 is used to bill for the procedure.
* Patient demographics* Ordering physician information* Date of service* Specimen collection date and time* Specimen type (cervical/vaginal)* Method of specimen collection* Microscopic findings (Bethesda System reporting)* Physician's interpretation and diagnosis (if abnormal)* Any ancillary testing performed
** Always confirm payer-specific coding requirements and ensure appropriate documentation to support medical necessity and accurate coding. The Bethesda System is a standardized reporting system, not a specific test methodology.
- Revenue Code: T1H (LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE))
- RVU: RVUs will vary based on geographic location, payer, and other factors. Consult your specific payer's fee schedule for the most up-to-date RVU information.
- Global Days: Not applicable. This is a laboratory procedure, not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable.This code represents the entire technical component of the procedure.
- Fee Schedule: Historical fee schedule data is not readily available and would require access to specific payer fee schedules and historical databases. This information changes regularly.
- Specialties:Obstetrics and Gynecology, Pathology, Family Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center, Laboratory