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Official Description

Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 87210 refers to a laboratory procedure known as a smear, specifically a primary source smear with interpretation, utilizing a wet mount technique to identify infectious agents. This procedure is essential in the diagnostic process for various infections, as it allows for the direct observation of microorganisms in clinical specimens. The wet mount technique involves preparing a sample by placing it in a thin layer on a microscope slide, which is then mixed with a suitable medium such as saline, India ink, or potassium hydroxide (KOH) solution. These preparations help to enhance the visibility of infectious agents, such as Trichomonas, yeast, and clue cells, which are commonly associated with infections in vaginal or cervical secretions, bronchial washings, sputum, body tissues, or biopsy aspirates. The examination is conducted under a microscope, where the laboratory technician looks for active movement of the infectious agents, allowing for their identification and quantification. Following the examination, a written report detailing the findings is generated, providing critical information for the healthcare provider to guide further clinical management.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 87210 is indicated for the identification of infectious agents in various clinical specimens. The following conditions or symptoms may warrant the performance of this test:

  • Vaginal/Cervical Infections The test is commonly performed to diagnose infections in vaginal or cervical secretions, where the presence of infectious agents can lead to conditions such as vaginitis or cervicitis.
  • Respiratory Infections It is also indicated for bronchial washings and sputum samples to identify pathogens responsible for respiratory infections.
  • Body Tissue Infections The procedure may be utilized for body tissue or biopsy aspirates to detect infectious agents in various tissues.

2. Procedure

The procedure for CPT® Code 87210 involves several key steps to ensure accurate identification of infectious agents. The following outlines the procedural steps:

  • Sample Collection A sample is collected from the primary source, which may include vaginal or cervical secretions, bronchial washings, sputum, body tissue, or biopsy aspirate. The collection is performed using an appropriate method, such as an inoculation hook or culturette swab, to ensure that the specimen is representative of the area being tested.
  • Preparation of the Slide The collected material is then applied in a thin layer onto a microscope slide. This step is crucial as it allows for optimal viewing of the sample under the microscope.
  • Mixing with Medium The specimen is mixed with a suitable medium, which may include saline, India ink, or KOH solution. This mixing helps to preserve the integrity of the sample and enhances the visibility of the infectious agents.
  • Microscopic Examination The prepared slide is examined under a microscope. The technician looks for active movement of the infectious agents, which is a key indicator of their presence. The identification and counting of these agents are performed during this examination.
  • Reporting Findings After the examination, a written report is generated, detailing the findings of the microscopic analysis. This report is essential for the healthcare provider to make informed decisions regarding patient management and treatment.

3. Post-Procedure

Post-procedure care for CPT® Code 87210 typically involves the interpretation of the results by a qualified healthcare professional. The findings from the wet mount examination are documented in a report, which may include the types and quantities of infectious agents identified. Based on the results, further clinical actions may be recommended, such as additional testing, treatment options, or follow-up evaluations. It is important for healthcare providers to communicate the results to the patient and discuss any necessary next steps in their care plan.

Short Descr SMEAR WET MOUNT SALINE/INK
Medium Descr SMR PRIM SRC WET MOUNT NFCT AGT
Long Descr Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)
Status Code Statutory Exclusion (from MPFS, may be paid under other methodologies)
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 9 - Not Applicable
Multiple Procedures (51) 9 - Concept does not apply.
Bilateral Surgery (50) 9 - Concept does not apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 9 - Concept does not apply.
Co-Surgeons (62) 9 - Concept does not apply.
Team Surgery (66) 9 - Concept does not apply.
Diagnostic Imaging Family 99 - Concept Does Not Apply
CLIA Waived (QW) Yes
APC Status Indicator Conditionally packaged laboratory tests
Type of Service (TOS) 5 - Diagnostic Laboratory
Berenson-Eggers TOS (BETOS) T1H - Lab tests - other (non-Medicare fee schedule)
MUE 4
CCS Clinical Classification 206 - Microscopic examination (bacterial smear, culture, toxicology)
QW Clia waived test
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
90 Reference (outside) laboratory: when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
Q4 Service for ordering/referring physician qualifies as a service exemption
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
91 Repeat clinical diagnostic laboratory test: in the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. note: this modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. this modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). this modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GA Waiver of liability statement issued as required by payer policy, individual case
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG Policy criteria applied
CR Catastrophe/disaster related
FP Service provided as part of family planning program
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GX Notice of liability issued, voluntary under payer policy
GZ Item or service expected to be denied as not reasonable and necessary
HN Bachelors degree level
KX Requirements specified in the medical policy have been met
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SA Nurse practitioner rendering service in collaboration with a physician
U6 Medicaid level of care 6, as defined by each state
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
X3 Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2011-01-01 Changed Short description changed.
2001-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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