How To Use CPT Code 88172

CPT 88172 describes the evaluation of a fine needle aspirate specimen through cytopathology. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88172?

CPT 88172 can be used to describe the evaluation of a fine needle aspirate specimen through cytopathology. This code represents the first evaluation episode, where the lab analyst performs the necessary steps to determine if the sample obtained is sufficient for diagnosis. The clinician obtains the specimen through a fine needle aspirate from various sources, such as masses, lymph nodes, liver, salivary glands, or thyroid. The analyst then immediately analyzes the specimen to ensure an adequate sample for further testing.

2. Official Description

The official description of CPT code 88172 is: ‘Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site.’ This code represents the initial evaluation of a fine needle aspirate specimen to determine if it is sufficient for diagnosis. It is important to note that an evaluation episode is independent of the number of needle passes or slides prepared.

3. Procedure

1. The clinician obtains a fine needle aspirate specimen from the patient, typically from a mass, lymph node, liver, salivary gland, or thyroid.
2. The lab analyst immediately analyzes the specimen to determine if it is sufficient for diagnosis.
3. The analyst performs all necessary technical steps to evaluate the cytopathology specimen and assess its adequacy.
4. The analyst provides a report to the clinician regarding the adequacy of the specimen for diagnosis.
5. If additional evaluations are performed on the same site during a separate evaluation episode, an additional code (+88177) should be reported.

4. Qualifying circumstances

CPT 88172 is used when evaluating a fine needle aspirate specimen for diagnosis. It is typically ordered when the clinician wants to immediately assess the adequacy of the specimen to avoid the need for additional tests due to an insufficient sample. The code applies to specimens obtained from various sources, including masses, lymph nodes, liver, salivary glands, or thyroid.

5. When to use CPT code 88172

CPT code 88172 should be used when the clinician wants to evaluate the adequacy of a fine needle aspirate specimen for diagnosis. It is appropriate to use this code for the first evaluation episode, where the lab analyst performs the necessary steps to determine if the sample obtained is sufficient. If additional evaluations are performed on the same site during a separate evaluation episode, an additional code (+88177) should be reported.

6. Documentation requirements

To support a claim for CPT 88172, the following documentation is required:

• Indication of the need for the evaluation of the fine needle aspirate specimen
• Details of the site from which the specimen was obtained
• Date and time of the evaluation episode
• Results of the evaluation and assessment of specimen adequacy
• Signature of the lab analyst performing the evaluation

7. Billing guidelines

When billing for CPT 88172, ensure that the evaluation episode represents a complete set of cytologic material submitted for evaluation. It is important to note that an evaluation episode is independent of the number of needle passes or slides prepared. If additional evaluations are performed on the same site during a separate evaluation episode, the add-on code +88177 should be reported. Modifier 59 should not be used when reporting multiple units of +88177.

8. Historical information

CPT 88172 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been historical changes to the code, including code changes in 2001 and 2011. The current description reflects the immediate cytohistologic study to determine adequacy for diagnosis.

9. Examples

1. A clinician performs a fine needle aspirate on a patient’s thyroid and immediately sends the specimen for evaluation to determine its adequacy for diagnosis.
2. A patient presents with a lymph node mass, and the clinician performs a fine needle aspirate to obtain a specimen. The lab analyst evaluates the specimen to assess its adequacy for diagnosis.
3. A clinician aspirates fluid from a salivary gland and sends the specimen for immediate evaluation to determine if it is sufficient for diagnosis.
4. A fine needle aspirate is performed on a liver mass, and the lab analyst analyzes the specimen to assess its adequacy for diagnosis.
5. A patient undergoes a fine needle aspirate on a breast mass, and the lab analyst immediately evaluates the specimen to determine if it is sufficient for diagnosis.
6. A clinician obtains a fine needle aspirate from a mass in the abdomen, and the lab analyst performs an immediate evaluation to assess the adequacy of the specimen for diagnosis.
7. A patient presents with multiple lymph nodes, and the clinician performs fine needle aspirates on each node. The lab analyst evaluates each specimen separately to determine their adequacy for diagnosis.
8. A clinician aspirates fluid from a cyst in the neck, and the lab analyst immediately evaluates the specimen to assess its adequacy for diagnosis.
9. A fine needle aspirate is performed on a mass in the lung, and the lab analyst analyzes the specimen to determine if it is sufficient for diagnosis.