Breast Discharge Cytology

CPT: 88161
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Test Details

Synonyms

  • Breast Smear
  • Nipple Discharge

Use

Diagnose primary or metastatic malignant neoplasms; differential diagnosis of benign versus malignant processes; aid in the diagnosis of infectious and inflammatory disease

Limitations

Drying of smear(s) before fixation will render specimen unsatisfactory for evaluation.

Methodology

Pap stained: microscopic examination

Specimen Requirements

Specimen

Nipple discharge

Volume

Pea-size drop

Container

Cardboard or plastic slide holder(s), Coplin jar(s)

Collection

Gently grip subareolar area and nipple with thumb and forefinger. When secretion occurs, allow pea-sized drop to accumulate on apex of nipple. Touch a clean slide to the nipple and withdraw quickly. Immediately spray slide with fixative or place slides in 95% ethyl alcohol. Repeat procedure until all secretions from nipple are collected on two or more slides. Using a graphite pencil, label the frosted end of the slide with the patient's name.

Storage Instructions

Maintain specimen at room temperature.

Causes for Rejection

Improper labeling; improper fixative; air-drying artifact

Clinical Information

Special Instructions

Include patient's name, date of birth, sex, Social Security number, previous malignancy, drug therapy, radiation therapy, mammogram, and all other pertinent clinical information on the request form.

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
009134 Breast Discharge Cytology 191115 Specimen type: 22633-2
009134 Breast Discharge Cytology 191152 Source: 22633-2
009134 Breast Discharge Cytology 191160 Clinician provided ICD9: 52797-8
009134 Breast Discharge Cytology 191174 Clinician provided ICD10: 52797-8
009134 Breast Discharge Cytology 191158 ****************************** N/A
009134 Breast Discharge Cytology 191118 DIAGNOSIS: 22637-3
009134 Breast Discharge Cytology 191165 Recommendation: 22638-1
009134 Breast Discharge Cytology 191140 Comment: 22638-1
009134 Breast Discharge Cytology 191159 ****************************** N/A
009134 Breast Discharge Cytology 191157 Pathologist provided ICD9: 52797-8
009134 Breast Discharge Cytology 191175 Pathologist provided ICD10: 52797-8
009134 Breast Discharge Cytology 191117 Clinical history: 22636-5
009134 Breast Discharge Cytology 191126 Amended report: N/A
009134 Breast Discharge Cytology 191127 Addendum: 22639-9
009134 Breast Discharge Cytology 191147 Diagnosis provided by: N/A
009134 Breast Discharge Cytology 191119 Signed out by: 19139-5
009134 Breast Discharge Cytology 191120 Performed by: N/A
009134 Breast Discharge Cytology 191116 Gross description: 22634-0
009134 Breast Discharge Cytology 191156 Microscopic description: 22635-7
009134 Breast Discharge Cytology 191141 Special procedure: N/A
009134 Breast Discharge Cytology 191179 Previous history: N/A
009134 Breast Discharge Cytology 191144 QA comment: N/A
009134 Breast Discharge Cytology 019018 . 11546-9
009134 Breast Discharge Cytology 000000 NonGyn CPT Code Automation N/A
009134 Breast Discharge Cytology 191167 Photomicrograph N/A

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CPT Statement/Profile Statement

The LOINC® codes are copyright © 1994-2017, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. Permission is granted in perpetuity, without payment of license fees or royalties, to use, copy, or distribute the LOINC® codes for any commercial or non-commercial purpose, subject to the terms under the license agreement found at https://loinc.org/license/. Additional information regarding LOINC® codes can be found at LOINC.org, including the LOINC Manual, which can be downloaded at LOINC.org/downloads/files/LOINCManual.pdf