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Cytopathology examination, specifically for cervical or vaginal samples, is a diagnostic procedure aimed at identifying cellular changes that may indicate the presence of disease. This examination is crucial for detecting abnormalities such as cervical dysplasia and in situ carcinoma, which are precursors to invasive malignancies. The procedure is commonly known as a Papanicolaou (PAP) smear, a test that involves collecting cells from the cervix or vagina for microscopic evaluation. After the PAP smear is processed using any reporting system, a pathologist interprets the findings to assess the cellular structure. If the results show any abnormalities, the pathologist may suggest follow-up actions, which could include scheduling another PAP smear sooner than the standard interval or conducting further diagnostic tests like colposcopy, endocervical curettage, or biopsy to ensure comprehensive evaluation and management of potential health issues.
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The cytopathology examination using CPT® Code 88141 is indicated for the following conditions:
The procedure for cytopathology examination involves several key steps that ensure accurate diagnosis and interpretation of cervical or vaginal samples:
Post-procedure care following a cytopathology examination typically involves monitoring the patient for any abnormal results. If the findings are abnormal, the pathologist may recommend a follow-up PAP smear at a shorter interval than usual to closely monitor the situation. Additionally, further diagnostic tests such as colposcopy, endocervical curettage, or biopsy may be suggested to obtain more definitive information regarding the cellular changes observed. Patients should be informed about the importance of follow-up appointments and any additional tests that may be necessary to ensure comprehensive care and management of their health.
| Short Descr | CYTOPATH C/V INTERPRET | Medium Descr | CYTP CERVICAL/VAGINAL REQ INTERP PHYSICIAN | Long Descr | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 2 - Professional Component Only Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | T1G - Lab tests - other (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.
| 0831T | Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician (List separately in addition to code for primary procedure) |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | GA | Waiver of liability statement issued as required by payer policy, individual case | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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. | GZ | Item or service expected to be denied as not reasonable and necessary | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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. | 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. | 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. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | 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 | 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) | PA | Surgical or other invasive procedure on wrong body part | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | 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 | QC | Single channel monitoring | RT | Right side (used to identify procedures performed on the right side of the body) | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2024-01-01 | Changed | Guideline information changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2006-01-01 | Changed | Code description changed. |
| 2005-01-01 | Changed | Code description changed. |
| 1998-01-01 | Added | First appearance in code book in 1998. |
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