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The CPT® Code 88177 pertains to cytopathology, specifically focusing on the evaluation of fine needle aspirates (FNAs). This procedure involves an immediate cytohistologic study aimed at determining the adequacy of the specimen for diagnostic purposes. In simpler terms, a fine needle aspiration is conducted to collect fluid or tissue samples from a specific site in the body. Following an initial evaluation episode, which is also reportable separately, additional evaluations may be performed on the same specimen to assess whether it is adequate for diagnosis. During this process, the collected cells are placed on a slide, where they typically form clusters of approximately ten cells each. A smear is created by placing another slide on top of the first, and various stains may be applied to enhance the visibility of cellular details. The physician then examines the specimen under a microscope to check for signs of disease, including malignancy. The accuracy of the diagnosis improves significantly when there are at least six cell clusters available for review. If the sample is found to be inadequate, the physician may decide to repeat the aspiration procedure. It is important to report code 88177 for each additional separate evaluation episode conducted on a specimen from the same site after the initial evaluation has been completed.
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The procedure associated with CPT® Code 88177 is indicated for the evaluation of fine needle aspirates when there is a need to assess the adequacy of the specimen for diagnostic purposes. This may include situations where there is a suspicion of malignancy or other pathological conditions that require cytological examination. The following are specific indications for performing this procedure:
The procedure for CPT® Code 88177 involves several key steps to ensure the adequacy of the specimen obtained through fine needle aspiration. The following procedural steps are outlined:
Post-procedure care following the evaluation of fine needle aspirates typically involves monitoring the patient for any immediate complications, such as bleeding or infection at the aspiration site. Patients may be advised to observe the site for any unusual symptoms and to follow up with their healthcare provider for results and further management based on the findings of the cytological evaluation. If the specimen is deemed inadequate, the physician may discuss the need for repeating the aspiration procedure to obtain a sufficient sample for diagnosis.
| Short Descr | CYTP FNA EVAL EA ADDL | Medium Descr | CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL | Long Descr | Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | 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 | 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 | 6 | CCS Clinical Classification | 234 - Pathology |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 0836T | Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure) | 88172 | Female Edit MPFS Status: Active Code APC Q1 CPT Assistant Article Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site | 0836T | Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | 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 | RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | Q5 | Service furnished under a reciprocal billing 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | 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. | 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. | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary |
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| 2024-01-01 | Changed | Guideline added. |
| 2011-01-01 | Added | Added |
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