Pathology/Lab Coding Alert

Question: A physician sends a Pap smear to the pathologist for interpretation based on the patient's history of abnormal Paps. Can we report 88141 for the service?

Ohio Subscriber

Answer: No, you cannot claim a pathologist's Pap smear interpretation based on patient history. You can only list 88141 (Cytopathology, cervical or vaginal [any reporting system], requiring interpretation by physician) when the person screening the Pap smear (usually a cytotechnologist) reports atypical or abnormal findings and submits the slides for pathology interpretation.

Pitfall: You can't always list 88141 when the pathologist examines a Pap smear. If the exam is for reasons other than abnormal findings, such as quality control, or because the pathologist is performing the initial Pap screening instead of a cytotechnologist, you can only claim the technical service.

Do this: In the example you give, you should report the Pap smear using the appropriate technical code based on the lab method used, such as 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision).

Only if the individual performing the screening (whether cytotechnologist or pathologist) reports findings such as "reactive cellular changes" denoting an abnormal Pap can the pathologist perform and report the interpretation service (88141).