• Note 1: ROSE CPT codes for immediate adequacy interpretations may only be billed if the diagnosis is made by an attending pathologist
• Note 2: each different anatomical site for which ROSE is performed during biopsy is billed separately
• 88172 - aspirate smear, first pass
• 88177 - aspirate smear, all subsequent passes
• 88333 - touch preparation, first pass
• 88334 - touch preparation, all subsequent passes

Contributed by Austin B. Wiles, M.D.


Images hosted on other servers:

• ROSE can optimize the performance of biopsy procedures benefitting the patient in 3 general capacities:
  • Reducing the number of passes made during a biopsy procedure and the overall number of procedures necessary to obtain a treatable diagnosis (Cancer Cytopathol 2013;121:518)
  • Informing the efficient disposition of cellular material for subsequent diagnostic and ancillary testing, including obtaining sufficient material necessary for anticipated diagnostic immunohistochemical studies, flow cytometry and theragnostic molecular testing (Cancer Cytopathol 2013;121:544)
  • Performance of ROSE can reduce the cost to obtain a diagnosis depending on a number of factors, including the availability of equipment, laboratory staff and procedure frequency (PLoS One 2015;10:e0135466)
• Utility of ROSE may be limited in some circumstances:
  • Cysts: only small volumes of cyst fluid may be analyzed generally obviating the utility of ROSE (Cibas: Cytology - Diagnostic Principles and Clinical Correlates, 5th Edition, 2021)
  • Solid pancreatic lesions sampled via needle core biopsy (Surg Endosc 2017;31:225)
  • Core depletion: depletion of diagnostic material from needle cores due to improper touch preparation technique (J Am Soc Cytopathol 2020;9:322)
• Pathology ancillary studies prompted by ROSE may include:
  • Recording formalin fixation time for lesions of suspected breast origin (Am J Clin Pathol 2018;149:275)
  • Molecular testing (Curr Oncol 2017;24:103, Acta Cytol 2016;60:372)
  • Microbiological cultures (Cancer Cytopathol 2018;126:643, Cancer Cytopathol 2015;123:612)
  • Flow cytometry (Acta Cytol 2016;60:302)
• There is no standard staining protocol for performing ROSE but maintenance of the stain line should occur according to laboratory standards
  • Diff-Quik Romanowsky stain is commonly used for ROSE slides (CAP Today: Cytopathology and More | FNA Cytology - Rapid On-Site Evaluation - How Practice Varies [Accessed 20 December 2021])
  • Rapid or ultrafast Papanicolaou, toluidine blue, rapid hematoxylin and eosin stains or brilliant cresyl blue may be used (J Cytol 2012;29:241, J Int Med Res 2019;47:626, Diagn Cytopathol 2019;47:469)
• ROSE can be performed via telepathology following validation (Diagn Cytopathol 2019;47:206, Cytopathology 2020;31:402)
• Equipment necessary for a ROSE procedure:
  • Adequate workspace
  • Disposable workpad (i.e., Chux pad)
  • Microscope
  • Power source for microscope
  • Stain line
  • Coplin jar
  • Pencil and pencil sharpener
  • Blank slides
  • Slide box
  • RPMI tubes and holders
  • Formalin jars
  • Needles for manipulating tissue
  • Steel needle holder
  • Needle disposal box
  • Biohazard trash receptacle
  • Cleaning supplies
  • Secure storage
  • Note 1:
    • Equipment may be brought by the pathologist or stored in the procedure room
    • All equipment must be maintained according to accreditation protocols regardless of its storage site
  • Note 2: see Diagrams / tables for a depiction of a portable cart containing all the above items
• Personnel:
  • ROSE may be provided by a single pathologist
  • An assistant may be very useful, as they can work on preparing slides while the pathologist renders interpretations

Images hosted on other servers:

A radiologist performs an ultrasound guided fine needle aspiration biopsy of a liver mass obtaining 4 passes from a single anatomic site. Aspirate smears from each pass were evaluated by an attending pathologist during rapid on site evaluation (ROSE). A preliminary interpretation was given to the radiologist for each pass and was subsequently recorded in the patient record in a preliminary report. What CPT codes are appropriate for the ROSE portion of this procedure?

1. 88172x1 and 88177x3
2. 88172x4
3. 88307x1
4. 88333x1 and 88334x3
5. 88333x4

A. 88172x1 and 88177x3 (see CPT coding)

Comment Here

Reference: Rapid on site evaluation (ROSE)

A radiologist performs a CT guided needle core biopsy of a soft tissue mass present in the quadriceps muscle of a patient obtaining 3 passes. Each needle core is transferred to an attending pathologist during rapid on site evaluation (ROSE). The pathologist gently manipulates each needle core on a glass slide to produce touch preparations and then transfers them to a formalin container for posterior processing in the cytology laboratory. Following staining an examination of the touch preparation slides, a preliminary interpretation of "scant spindle cells and blood" is provided to the radiologist following each pass. These results were recorded in the patient record in a preliminary report. Examination of the formalin fixed, paraffin embedded needle core tissue with H&E demonstrates a schwannoma which correlates well with the clinical and radiological impression. No immunohistochemical studies were necessary to produce the final diagnosis. What CPT codes should be applied to this pathology case?

1. 88172x1, 88177x2, 88305x1
2. 88172x3, 88305x1
3. 88307x1
4. 88333x1, 88334x2, 88307x1
5. 88333x3, 88307x1

D. 88333x1, 88334x2, 88307x1 (see CPT coding)

Comment Here

Reference: Rapid on site evaluation (ROSE)

The practices and terminologies used to perform rapid on site evaluation (ROSE) are

1. Delineated by CLIA '88 and the College of American Pathologists
2. Regulated and informed by standards established by the American Society of Cytopathology
3. Universal and standardized
4. Vary widely between institutions

D. Vary widely between institutions. The practice, terminologies and equipment to perform ROSE vary widely between institutions and may even vary within institutions depending on the specific needs of clinical practices. Variation is influenced by organ site, clinical capabilities, local convention and individual judgement of the ROSE provider.

Comment Here

Reference: Rapid on site evaluation (ROSE)