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Cytopathology
Palpation Guided Fine Needle Aspiration
CTP™ and E/M codes

Author: Joe D. Jakowski, M.D. (see Reviewers page)
Revised: 18 August 2013, last major update August 2013
Copyright: (c) 2013, PathologyOutlines.com, Inc.

Current Procedural Technology (CPT)™ Coding (Partial List)

Procedure codes
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10021
Fine needle aspiration; without imaging guidance

Pathology professional and technical codes
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88172
Cytopathology, evaluation of fine needle aspirate; immediate evaluation for adequacy of specimen(s)

88173
Cytopathology, evaluation of fine needle aspirate; final interpretation and report

88305
CELL BLOCK: Level IV - Surgical pathology, gross and microscopic examination

88104
Cytopathology, fluids; smears with interpretation


Evaluation and management (E/M) codes (i.e. office visit codes)

General
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NEW patient E/M codes
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99201
Office or other outpatient visit (10 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Focused history
    2. Focused exam
    3. Straightforward medical decision
  2. Patient has a self limited or minor problem:
    1. Minimal number of diagnoses or management options
    2. Minimal or no data to be reviewed
    3. Minimal risk of complications, morbidity, mortality
  3. Physician time: 10 minutes
99202
Office or other outpatient visit (20 min) for the evaluation and management of a new patient which have these components or criteria for documentation and billing purposes
  1. Requires 3 key components:
    1. Expanded problem focused history
    2. Expanded problem focused exam
    3. Straightforward medical decision
  2. Patient has a low severity or moderate severity problem:
    1. Limited number of diagnoses or management options
    2. Limited amount or complexity of data to be reviewed
    3. Low risk of complications, morbidity, mortality
  3. Physician time: 20 minutes

Established patient E/M codes
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End of Cytopathology > Palpation Guided Fine Needle Aspiration > CTP™ and E/M codes


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