College of American Pathologists
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  Your CPT Questions


March 2007

Q: Can we use code 88172 for cases in which a cytotechnologist is present at a fine-needle aspiration performed by a radiologist and assesses specimen adequacy? The pathologist is not present at the time of aspirate and does not participate in the immediate assessment of adequacy.

A: CPT code 88172, Cytopathology, evaluation of fine-needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s), is a physician code and may not be reported when a cytotechnologist assesses specimen adequacy.

Q: We received a merkel cell carcinoma left cheek specimen that had cut sections and margins that were submitted in different cassettes (1A, 1B, 1C, 1D, 1D, 1E, 1F) and inked separately. Our doctor believes the amount of work involved here is greater than one code 88305, Level IV—surgical pathology, gross and microscopic examination. Can the specimen be coded to a higher level of gross and microscopic examination or to more than one code 88305?

A: CPT provides no additional consideration for evaluating margins on skin specimens. Furthermore, the number of cassettes does not influence which CPT code is selected. Type of specimen is the only criterion for code selection and, in this case, it would be 88305 times one unit of service.

Frequently asked questions about CPT are published bimonthly in “Capitol Scan.” This section of CAP TODAY is a product of the CAP Economic Affairs Committee. The codes and descriptions listed here are from Current Procedural Terminology, 4th ed., CPT 2007. CPT 2007 is copyrighted by the American Medical Association. To purchase CPT books, call the AMA at 800-621-8335.

For more information about CPT coding, visit the CPT Coding Resource Center on the CAP Web site.