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Official Description

Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

CPT® Code 88162 refers to a specific laboratory test within the field of cytopathology, which is the microscopic examination of cells that have either spontaneously exfoliated or have been collected from a body surface through methods such as washing or brushing. This code is utilized for extended studies that involve the analysis of more than five slides and/or the application of multiple stains to the samples. The primary purpose of this procedure is to diagnose various conditions, including malignant and premalignant diseases, infectious diseases, autoimmune disorders, inflammation, immune reactions, cell aging, and amyloidosis. The process begins with the collection of fluid, washing, or brushing samples, which are then prepared for microscopic examination. A technician or pathologist prepares the slides, and the pathologist subsequently examines them under a microscope to identify any abnormalities or diseases present in the cells. Following the examination, a written report detailing the findings is generated. This code is particularly relevant in cases where a more comprehensive analysis is required, as indicated by the need for multiple slides or stains, distinguishing it from other related codes that may pertain to simpler or less extensive cytopathological evaluations.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 88162 is indicated for the evaluation of various conditions that may affect cellular health and integrity. The following are the explicitly provided indications for performing this cytopathological study:

  • Malignant Disease - The test is used to identify cancerous cells that may indicate the presence of malignancy.
  • Premalignant Disease - It aids in detecting cellular changes that could lead to cancer if not monitored or treated.
  • Infectious Disease - The procedure can help diagnose infections by identifying pathogens within the cellular samples.
  • Autoimmune Disease - It is utilized to assess conditions where the immune system mistakenly attacks healthy cells.
  • Inflammation - The test can reveal inflammatory responses in tissues, which may indicate underlying health issues.
  • Immune Reactions - It helps in evaluating the body's immune response to various stimuli or conditions.
  • Cell Aging - The procedure can provide insights into cellular aging processes, which may be relevant in various health assessments.
  • Amyloidosis - It is used to detect the presence of amyloid deposits in tissues, which can indicate this specific disease.

2. Procedure

The procedure for CPT® Code 88162 involves several critical steps to ensure accurate cytopathological analysis. The following outlines the procedural steps:

  • Sample Collection - The first step involves obtaining samples from the patient, which may include fluid, washings, or brushings from various body surfaces. This collection is performed through a separately reportable procedure, ensuring that the samples are suitable for cytopathological examination.
  • Slide Preparation - Once the samples are collected, they are prepared for microscopic examination. This preparation may involve the technician or pathologist creating multiple slides from the collected samples, ensuring that the cellular material is adequately spread and fixed for analysis.
  • Microscopic Examination - The pathologist examines the prepared slides under a microscope. This examination is crucial for identifying any abnormal cellular characteristics that may indicate disease. The pathologist looks for signs of malignancy, premalignancy, infection, or other pathological conditions.
  • Staining - In cases where multiple stains are required, the pathologist applies various staining techniques to enhance the visibility of cellular structures and abnormalities. This step is essential for a comprehensive analysis, particularly when more than five slides are involved.
  • Reporting Findings - After the examination and analysis, the pathologist compiles a written report detailing the findings. This report includes observations regarding the cellular characteristics, any identified diseases, and recommendations for further action if necessary.

3. Post-Procedure

Post-procedure care for patients undergoing the cytopathological study associated with CPT® Code 88162 typically involves monitoring for any immediate reactions to the sample collection process. Since the procedure primarily focuses on laboratory analysis, there are no specific post-procedure restrictions or care requirements mentioned. However, patients may be advised to follow up with their healthcare provider to discuss the results of the cytopathological examination. The pathologist's report will guide any necessary further diagnostic steps or treatment options based on the findings. It is essential for healthcare providers to communicate the results effectively to the patient and to consider any additional evaluations or interventions that may be warranted based on the diagnosis.

Short Descr CYTOPATH SMEAR OTHER SOURCE
Medium Descr CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES
Long Descr Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
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 STV-Packaged Codes
Type of Service (TOS) 5 - Diagnostic Laboratory
Berenson-Eggers TOS (BETOS) T1G - Lab tests - other (Medicare fee schedule)
MUE 3
CCS Clinical Classification 234 - Pathology

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

0834T Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains (List separately in addition to code for primary procedure)
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.
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.
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
GW Service not related to the hospice patient's terminal condition
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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2024-01-01 Changed Guideline information changed.
2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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