Proper CPT-coding of a non-gyn cytology specimen depends principally on the type of preparation that’s performed for screening and examination. The most common non-gyn cytology specimens submitted are washings (such as bronchial, bladder, and esophageal), brushings, urines (voided or catheterized), and body fluid aspirates (pleural fluid, peritoneal fluid, and spinal fluid). The type of specimen isn’t relevant to the coding decision; the method of preparation points to the correct CPT code for the service. The pathology report should clearly document this information. CPT codes for the most common preparations - 88104, 88108, 88112, and 88160 - are billed once per specimen, not per slide or preparation.
• Direct Smear 88104-Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
• Cellular/Enriched Smear 88112-Cytopathology, selective cellular enhancement technique with interpretation (liquid-based slide preparation method, thin-prep), except cervical or vaginal Note-Per CPT 88112 cannot be reported with 88108 for the same specimen
• Smears; any other source 88160-Cytopathology, smears, any other source; screening and interpretation. “Any other source” is mainly sputum, nipple discharge (when not concentrated) and Tzanck smears.
Additional services can be performed on cytology specimens such as a cell block to clarify the diagnosis from the smears. This is charged separately using CPT code 88305. Only one cell block is billable per specimen, even when performed on multiple blocks. If special stains are performed that are not routine, they also can be reported separately with the appropriate CPT code, 88312 or 88313.
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