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Cytopathology examination, specifically for cervical or vaginal specimens, is a critical diagnostic procedure aimed at identifying cellular changes that may indicate the presence of disease. This examination is particularly important for detecting conditions such as cervical dysplasia and in situ carcinoma, which are precursors to invasive malignant diseases. The procedure is commonly known as a Papanicolaou (PAP) smear, where cells are collected from the endocervix using specialized tools like a brush or stick. These collected specimens are then placed in a preservative fluid to maintain cell integrity during transport to the laboratory. Once at the laboratory, the specimen undergoes a process where the liquid cell suspension is centrifuged to eliminate debris, allowing for a concentrated retrieval of cervical cells. The preparation of these cells involves an automated system that stains the cells and transfers them onto slides, which are then covered with slips for protection. The automated system plays a crucial role in screening and interpreting the prepared smears, enhancing the efficiency and accuracy of the examination. In the context of CPT® Code 88175, the automated screening results are further evaluated by a trained technician who performs manual rescreening of the PAP smear under the supervision of a physician, typically a pathologist. This manual rescreening entails a thorough reassessment of the entire slide to ensure that any abnormal findings are accurately identified. If abnormalities are detected, the pathologist may suggest follow-up actions, such as scheduling another PAP smear sooner than the standard interval or conducting additional diagnostic tests like colposcopy, endocervical curettage, or biopsy to further investigate the findings.
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The cytopathology examination using CPT® Code 88175 is indicated for the following conditions:
The procedure for CPT® Code 88175 involves several key steps to ensure accurate cytopathological evaluation:
After the cytopathology examination is completed, the pathologist reviews the findings. If any abnormalities are detected during the manual rescreening, the pathologist may recommend follow-up actions. These may include scheduling another PAP smear at a shorter interval than usual or performing additional diagnostic tests such as colposcopy, endocervical curettage, or biopsy to further evaluate the cervical cells. It is essential for patients to follow up on any recommendations made by their healthcare provider to ensure timely monitoring and treatment of any identified conditions.
| Short Descr | CYTOPATH C/V AUTO FLUID REDO | Medium Descr | CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS | Long Descr | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, 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) |
| 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. | GA | Waiver of liability statement issued as required by payer policy, individual case | 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. | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 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. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | 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 | 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 | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | 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 | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | QW | Clia waived test | SA | Nurse practitioner rendering service in collaboration with a physician | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2006-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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