CPT® Code 88165

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision

The CPT® Code 88165 refers to a specific cytopathology procedure involving the analysis of cervical or vaginal slides using the Bethesda System. This procedure is commonly known as a Papanicolaou (PAP) smear, which is a critical screening tool for detecting cervical cancer and other abnormalities in cervical cells. The Bethesda System is the predominant reporting framework utilized in the United States for interpreting PAP smear results. It provides a standardized method for reporting the adequacy of the specimen collected, identifying any signs of infection, and categorizing cellular changes. These changes may include benign alterations, atypical squamous cells of undetermined significance (ASCUS), atypical glandular cells of undetermined significance (AGCUS), and various degrees of dysplasia or squamous intraepithelial lesions (SIL), which are further classified into low-grade (LGSIL) and high-grade (HGSIL) lesions, as well as carcinoma. During the procedure, cells are collected from the endocervix using a specialized brush or stick, and the specimen is then smeared onto a glass slide. The slide is fixed using either a spray or immersion technique and subsequently covered with a coverslip. Once prepared, the slide is sent to a cytology laboratory for staining. A trained technician screens the slide under a microscope to identify any abnormalities in the cells. In the context of CPT® Code 88165, the technician performs a manual screening of the slide while under the supervision of a physician. This code also includes a rescreening process that utilizes computer assistance to enhance the detection of suspicious single cells and abnormal cell structures. The technician reviews the findings from both the manual and computer-assisted screenings to ensure a comprehensive evaluation of the specimen. This thorough approach is essential for accurate diagnosis and subsequent management of any identified abnormalities.