Reprinted from February 2001 CAP TODAY
Q: How do you code sputum submitted for cytological evaluation? Should
I use codes 88104 and 88162 if more than five slides are submitted or
prepared or should I use code 88160?
A: If the pathologist reviews fewer than five direct smears prepared
from the sputum specimen, submit code 88160, Cytopathology, smears,
any other source; screening and interpretation. If more than five
slides are reviewed or more than one stain is used, submit code 88162,
Cytopathology smears, any other source; extended study involving more
than 5 slides and/or multiple stains. If the sputum is concentrated
using, for example, Thin Prep or cytospin and slides are prepared, then
code 88108, Cytopathology, concentration technique, smears and interpretation
(e.g., Saccomanno technique), should be submitted (CPT Assistant,
January 1998). If a cell block is prepared, code 88305, Cell Block,
Any Source, should also be submitted with the cytology code.
The 88160 family (88160-88162) is used for cytology specimens that are
not otherwise reported by the other cytology codes (this applies to such
specimens as fine-needle aspirations, gynecological specimens, nongynecological
fluids, washings, or brushings). It would be appropriate to use the 88160
family to code the smears from specimens such as sputum, imprints from
tissue, or nipple discharge.
Q: I recently heard that a lymph node submitted for lymphoma should
be coded using 88307 because it is more like a soft tissue mass than a
lymph node biopsy. Is this appropriate use of the code?
A: The instructions in the CPT book say, “Select the name of the
procedure that most accurately identifies the service performed.” The
preamble to the surgical pathology section states, “Levels 88302 through
88309 are specifically defined by the assigned specimens.” A lymph node
biopsy, therefore, should be coded using 88305, Lymph Node, Biopsy,
regardless of the reason for removal. Unusually difficult or time-consuming
cases should be reported using modifier -22, Unusual Procedural Services.
Medicare, however, will not increase payment when the modifier is used,
and many private insurers do not recognize the modifier.
Frequently asked questions about CPT are published bimonthly in “Capitol
Scan.” This addition to CAP TODAY is a product of the CAP Economic
The codes and descriptions listed here are from Current Procedural Terminology,
a copyrighted publication of the American Medical Association. To purchase
CPT books, call the AMA at (800) 621-8335.