How To Use CPT Code 88177

CPT 88177 describes the evaluation of a fine needle aspirate specimen through cytopathology. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88177?

CPT 88177 can be used to describe the evaluation of a fine needle aspirate specimen through cytopathology. This code is used for each separate additional evaluation episode after the first on the same site. It is important to note that this code should be reported in conjunction with CPT code 88172.

2. Official Description

The official description of CPT code 88177 is: ‘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).’ This code should be used when there is a need to evaluate the adequacy of a fine needle aspirate specimen for diagnosis.

3. Procedure

1. The clinician performs a fine needle aspirate to obtain a specimen from the patient.
2. The lab analyst immediately analyzes the specimen to determine if it is sufficient for diagnosis.
3. If the first evaluation episode is determined to be inadequate, subsequent evaluation episodes may be performed on the same site.
4. Each additional evaluation episode involves the lab analyst examining the cytologic material to ensure adequacy for diagnosis.

4. Qualifying circumstances

CPT 88177 is used when there is a need to evaluate the adequacy of a fine needle aspirate specimen for diagnosis. This code is typically used when the initial evaluation episode is determined to be inadequate and additional evaluation episodes are required. It is important to note that CPT 88177 should be reported in conjunction with CPT code 88172.

5. When to use CPT code 88177

CPT code 88177 should be used when there is a need to evaluate the adequacy of a fine needle aspirate specimen for diagnosis. This code is used for each separate additional evaluation episode after the first on the same site. It is important to report CPT 88177 in conjunction with CPT code 88172.

6. Documentation requirements

To support a claim for CPT 88177, the following documentation is required:

• Documentation of the need to evaluate the adequacy of the fine needle aspirate specimen for diagnosis
• Documentation of the specific site where the evaluation episode is performed
• Date and time of each evaluation episode
• Results of each evaluation episode and any subsequent actions taken
• Signature of the lab analyst performing the evaluation

7. Billing guidelines

When billing for CPT 88177, it is important to report this code in conjunction with CPT code 88172. Payers will not reimburse for CPT 88177 unless it is reported with an appropriate primary code. Multiple units of CPT 88177 can be reported without a modifier, as it is an add-on code. Modifier 59 should not be used when reporting multiple adequacy checks for FNA specimens.

8. Historical information

CPT 88177 was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates to the code since its addition.

9. Examples

1. A clinician performs a fine needle aspirate on a patient’s lymph node. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to ensure adequacy for diagnosis.
2. A patient presents with a thyroid nodule, and a fine needle aspirate is performed. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to evaluate the specimen for diagnosis.
3. A clinician performs a fine needle aspirate on a patient’s liver mass. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to assess the specimen for diagnosis.
4. A patient undergoes a fine needle aspirate of a salivary gland. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to determine the adequacy of the specimen for diagnosis.
5. A clinician performs a fine needle aspirate on a patient’s breast mass. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to evaluate the specimen for diagnosis.
6. A patient presents with a lung nodule, and a fine needle aspirate is performed. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to assess the specimen for diagnosis.
7. A clinician performs a fine needle aspirate on a patient’s pancreatic mass. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to determine the adequacy of the specimen for diagnosis.
8. A patient undergoes a fine needle aspirate of a lymph node. The lab analyst determines that the initial evaluation episode was inadequate and performs an additional evaluation episode on the same site to evaluate the specimen for diagnosis.