US · guidance
CMS SOM App. C, Tag D5657
§493.1274 Standard: Cytology
(e)(5) The report contains narrative descriptive nomenclature for all results.
Interpretive Guidelines §493.1274(e)(5)
In cytology, great variation exists among the systems and terms a laboratory may use to
report patient results on cytology reports. The laboratory must specify the descriptive
nomenclature used for reporting patient results. This nomenclature must define the
criteria used to classify patient results in a particular category in a clear and concise
manner to ensure that all employees report patient results in a uniform, consistent
manner. Use of the Papanicolaou numerical system without narrative description is not
acceptable.
The Bethesda System is an example of a recognized system of narrative descriptive
nomenclature for gynecologic cytology.
Probes §493.1274(e)(5)
When cytology evaluations are recorded on worksheets in “code” how does the
laboratory ensure that the correct interpretation is used in reporting the results? Use
D5801.
History
Rev. 233; Issued: 09-12-25; Effective: 09-12-25; Implementation: 09-12-25
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
20c48d39dd302c0159d59dbe8bd3c6f1a8b04a7bf5c969a070177fabaaa51684
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