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2025 CPT code 88172

Evaluation of a fine needle aspirate (FNA) specimen; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode.

Refer to the CPT manual and payer-specific guidelines for detailed coding instructions.

Modifiers may be applicable depending on the circumstances of service. Consult the CPT manual for modifier usage guidelines.

Medical necessity for CPT code 88172 is established when there is a clinical indication for immediate assessment of the FNA specimen adequacy to guide further management. This might include situations where there's concern about obtaining a sufficient sample for diagnosis or the need for immediate information to proceed with treatment or further testing.

The clinical responsibility lies with the pathologist or qualified personnel who perform the immediate cytohistologic study to assess the adequacy of the FNA specimen.

IMPORTANT:For additional evaluations at the same site, use add-on code +88177.This code should not be used if a cytotechnologist performs the adequacy assessment.

In simple words: This lab test checks a sample taken with a thin needle to see if there's enough material for further testing to diagnose a disease. This is the first check of the sample.

This CPT code encompasses the initial evaluation of a fine needle aspirate (FNA) specimen by a pathologist or qualified personnel to assess its adequacy for subsequent diagnostic testing.The evaluation involves immediate microscopic examination of the aspirated material to determine if a sufficient quantity and quality of cells are present for further analysis. This code applies to the first evaluation episode at each site.Additional evaluations at the same site are reported using CPT code +88177.

Example 1: A physician performs an FNA of a thyroid nodule. The specimen is immediately sent to the laboratory for evaluation using CPT code 88172. The pathologist determines the sample is adequate for further cytologic examination., A radiologist performs an image-guided FNA of a suspicious lung mass.The specimen is sent to pathology for an immediate adequacy assessment using 88172. The pathologist finds the sample insufficient, requiring a repeat procedure. , A surgeon performs an FNA of a lymph node during a surgical procedure. The sample is evaluated immediately using 88172. The pathologist determines the specimen is adequate for further diagnostic testing to evaluate for malignancy.

* Complete patient demographics* Ordering physician information* Specimen source (e.g., thyroid, lymph node, lung)* Date and time of the FNA procedure* Pathologist's report indicating the adequacy assessment and the number of passes.

** This code should only be reported by the physician or qualified non-physician provider who interprets the results. This code is for the first evaluation episode only.Multiple passes from the same site during the same encounter are considered a single evaluation episode.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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