2025 CPT code 88165
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory Procedures - Cervical or Vaginal Cytopathology Cytopathology Screening Procedures Feed
Manual screening and rescreening of cervical or vaginal cytopathology slides using the Bethesda System under physician supervision.
Modifiers may be applicable depending on the specific circumstances. Consult payer guidelines for details.Example: Modifier 99 may be used for multiple procedures.
Medical necessity for a Pap smear is established by various factors, such as routine screening (based on age and guidelines), follow-up after abnormal results, or evaluation of symptoms (vaginal bleeding, discharge, etc.).Payers have specific guidelines for coverage.
The clinical responsibility lies primarily with the laboratory personnel for performing the technical analysis. The physician is responsible for oversight, interpretation of results (if abnormal), and patient management.
In simple words: This lab test involves a detailed manual check of a sample of cells from the cervix or vagina under a microscope. The technician examines the slide twice to ensure accuracy and reports the results using a standardized system.
This CPT code encompasses the technical component of analyzing cervical or vaginal cytopathology slides.A qualified lab analyst performs a manual microscopic examination of the slide, followed by a manual rescreening. The results are reported using the Bethesda System, which includes an assessment of specimen adequacy and categorization of findings (e.g., negative for intraepithelial lesion or malignancy, atypical squamous cells). This procedure is performed under the direct supervision of a physician.
Example 1: Annual well-woman exam: A 35-year-old female patient presents for her annual gynecological examination. As part of the exam, a cervical and vaginal Pap smear is collected and sent to the laboratory for analysis using code 88165., Follow-up after abnormal screening: A 40-year-old female patient had a previous Pap smear that showed atypical squamous cells of undetermined significance (ASC-US). A repeat Pap smear is performed, and code 88165 is used to bill for the manual screening and rescreening., Patient with vaginal discharge: A 28-year-old female patient presents with vaginal discharge and discomfort. Her physician orders a Pap smear to rule out any underlying infection or pathology.Code 88165 is utilized to bill the manual cytology evaluation.
* Patient demographics and relevant medical history.* Reason for the test (e.g., screening, abnormal previous results, symptoms).* Specimen collection details (date, time, type of collection device).* Laboratory report with results, including the Bethesda System classification.* Physician's order for the test and any interpretation notes.
** This code is specifically for manual screening and rescreening using the Bethesda System.If automated screening methods are used, different codes apply.
- Revenue Code: T1H (LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE))
- RVU: The RVUs for this code vary depending on the geographic location and payer.Consult the appropriate fee schedule for specific values.
- Global Days: Not applicable. This is a laboratory procedure, not a surgical procedure with a global period.
- Payment Status: Active
- Modifier TC rule: This is the technical component, there is no TC modifier applicable to this code. The professional component would require separate coding.
- Fee Schedule: Fee schedules vary by payer and location. Consult the relevant fee schedule.
- Specialties:Obstetrics and Gynecology, Pathology, Cytology
- Place of Service:Laboratory, Physician's Office