CPT® Code 88153

Official Description

Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision

Common Language Description

CPT® Code 88153 refers to the process of cytopathology specifically for cervical or vaginal specimens, where manual screening and rescreening are conducted under the supervision of a physician. This code is utilized for conventional Papanicolaou (PAP) smears that are analyzed using a non-Bethesda reporting system, which may include various classification systems such as the class system, dysplasia system, or cervical intraepithelial neoplasia (CIN) system. The primary purpose of a PAP smear is to identify any cellular changes that could indicate the presence of disease, particularly conditions like cervical dysplasia or in situ carcinoma. Early detection through this test is crucial as it allows for timely monitoring and intervention before these conditions can progress to invasive cancer. During the procedure, cells are collected from the endocervix using a specialized tool, such as a brush or stick. The collected specimen is then smeared onto a glass slide, fixed with either a spray or immersion method, and subsequently covered with a coverslip. This prepared slide is sent to a cytology laboratory where it undergoes staining to enhance visibility under a microscope. A trained technician then manually screens the slide for any abnormalities, identifying abnormal cells or clusters that may indicate disease. CPT® Code 88153 specifically involves a manual screening of the PAP smear, followed by a thorough manual rescreening, which may be conducted by a second technician. This comprehensive reassessment ensures a meticulous review of the entire slide. Additionally, the findings from the screening process are communicated to the treating physician, and if any abnormalities are detected, further recommendations may be made, such as scheduling another PAP smear sooner than usual or conducting additional diagnostic tests like colposcopy, endocervical curettage, or biopsy.

1. Indications

The procedure associated with CPT® Code 88153 is indicated for the following conditions:

Cervical Dysplasia - The presence of abnormal cells on the cervix that may indicate a precancerous condition.
In Situ Carcinoma - A type of cancer that is confined to the site of origin and has not invaded surrounding tissues.
Monitoring of Cervical Health - Regular screening to detect any changes in cervical cells that could lead to more serious conditions if left untreated.

2. Procedure

The procedure for CPT® Code 88153 involves several key steps that ensure accurate cytological evaluation of cervical or vaginal specimens:

Step 1: Specimen Collection - Cells are collected from the endocervix using a specialized tool, such as a brush or stick. This step is crucial as it gathers the necessary cellular material for examination.
Step 2: Slide Preparation - The collected specimen is smeared onto a glass slide. The slide is then fixed using either a spray or immersion method to preserve the cellular structure for analysis.
Step 3: Staining - The prepared slide is sent to a cytology laboratory where it undergoes staining. This process enhances the visibility of the cells under a microscope, allowing for better identification of abnormalities.
Step 4: Manual Screening - A trained technician manually screens the stained slide using a microscope. During this step, the technician looks for any abnormal cells or cell clusters that may indicate disease.
Step 5: Manual Rescreening - Following the initial screening, a complete manual rescreening of the entire slide is performed. This may be conducted by a second technician to ensure thoroughness and accuracy in identifying any potential abnormalities.
Step 6: Communication of Findings - The results of the screening are communicated to the treating physician. If any abnormalities are detected, the pathologist may recommend further actions, such as additional testing or follow-up PAP smears.

3. Post-Procedure

After the procedure associated with CPT® Code 88153, the expected post-procedure care includes monitoring the patient for any abnormal findings. If the results indicate abnormalities, the pathologist may suggest a follow-up PAP smear at a shorter interval than usual or recommend additional diagnostic tests such as colposcopy, endocervical curettage, or biopsy. It is essential for the treating physician to communicate the findings to the patient and discuss any necessary next steps in their care plan. Regular follow-up and adherence to recommended screenings are crucial for maintaining cervical health and preventing the progression of any detected abnormalities.

Short Descr	CYTOPATH C/V REDO
Medium Descr	CYTP SLIDES C/V MNL SCR&RESCR PHYS
Long Descr	Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision
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)	No
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	1
CCS Clinical Classification	234 - Pathology

This is a primary code that can be used with these additional add-on codes.

88155

Female Edit Addon Code MPFS Status: Statutory exclusion (from MPFS, may be paid under other methodologies) APC Q4 PUB 100 CPT Assistant Article Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code[s] for other technical and interpretation services)