2025 CPT code 88177
(Active) Effective Date: N/A Revision Date: N/A Laboratory - Cytopathology Procedures Pathology and Laboratory Feed
Additional evaluation of fine needle aspirate (FNA) specimen for adequacy; each separate additional episode after the first at the same site.
Modifiers may be applicable to 88177 depending on other procedures or circumstances.Consult the CPT manual and payer guidelines for specific modifier usage.
Medical necessity is established when the initial FNA specimen is insufficient for diagnosis, necessitating further evaluation.Documentation should justify the need for additional sampling and subsequent analyses.
The clinical responsibility lies with the laboratory personnel (cytotechnologists/pathologists) who perform the microscopic evaluation of the FNA specimen to assess its adequacy. The clinician obtains the specimen through the FNA procedure.
In simple words: This lab test checks if a sample taken with a thin needle is good enough for the doctor to make a diagnosis.This code is used only if there were extra checks needed after the first check on the same area of the body.
This CPT code, 88177, represents each additional evaluation episode of a fine needle aspirate (FNA) specimen performed to determine its adequacy for diagnosis.It's used after the initial evaluation (coded as 88172) on the same site. The evaluation involves the cytologic examination of the specimen to assess if sufficient cellular material is present for diagnostic purposes.The code is reported only when additional assessments are made after the initial one, each assessment constituting a separate evaluation episode.This is distinct from the number of needle passes taken during the FNA procedure.
Example 1: A surgeon performs an FNA on a thyroid nodule. The initial specimen is deemed inadequate by the pathologist. The surgeon performs two additional needle passes, and the pathologist evaluates each one separately.88172 is reported for the first evaluation, and 88177 is reported twice for the additional evaluations., A patient undergoes an FNA for a suspicious breast lump. The pathologist reviews the first slide and needs additional sampling for adequate cell count. The surgeon obtains additional passes and the pathologist evaluates those passes, thus warranting an additional code 88177., Multiple FNA passes are taken from a lymph node.The pathologist receives all the samples at once and determines the adequacy of the complete sample in one evaluation episode.Only code 88172 would be reported in this case.
Detailed documentation is crucial.The report should clearly indicate the number of evaluation episodes, the date and time of each evaluation, the adequacy assessment for each episode and whether the pathologist's findings impacted the need for further FNA passes. The report should also include information about the site, the type of tissue sampled, and the reason for performing the FNA.
** The number of passes in the FNA procedure does not dictate the number of units of 88177. The critical factor is the number of separate evaluation episodes required to determine adequacy for diagnosis.
- Revenue Code: T1H (LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE))
- RVU: This information is not available in the provided sources and requires access to specific payer fee schedules and relative value unit (RVU) data.
- Global Days: Not applicable; this is a laboratory procedure, not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: The technical component (TC) modifier does not apply to this code as it is a professional service performed by the pathologist.The pathologist's interpretation of the samples' adequacy is considered a professional service, distinct from the technical procedure of collecting the sample.
- Fee Schedule: The provided sources do not contain historical fee schedule data.This information can be obtained from payer-specific fee schedules and historical billing data.
- Specialties:Pathology, Cytopathology, Oncology, Surgery (depending on the context of the FNA)
- Place of Service:Office, Hospital (Inpatient/Outpatient), Ambulatory Surgical Center, other clinical settings where FNA procedures and cytopathology interpretations are performed.