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Official Description

Radiological examination, surgical specimen

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 76098 refers to the radiological examination of a surgical specimen, a critical procedure performed by pathologists. This examination is essential for orienting the surgical specimen accurately and identifying specific areas that require biopsy. During this process, the pathologist utilizes radiographic imaging to visualize the specimen, which aids in determining the tumor margins in relation to various markers, such as sutures or wires that may be present. By localizing the targeted area through the radiograph, the pathologist can effectively obtain tissue samples that are subsequently prepared for microscopic examination. The code 76098 specifically captures the radiographic viewing and examination of the surgical specimen, highlighting its importance in the overall diagnostic and treatment process.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The radiological examination of a surgical specimen, as represented by CPT® Code 76098, is indicated in various clinical scenarios where precise evaluation of the specimen is necessary. The following conditions may warrant this procedure:

  • Pathological Assessment The examination is performed to assist in the pathological assessment of the specimen, ensuring accurate diagnosis and treatment planning.
  • Tumor Margin Evaluation It is indicated for evaluating tumor margins, which is crucial for determining the extent of disease and ensuring complete removal of malignant tissues.
  • Biopsy Localization The procedure is utilized for localizing specific areas within the specimen that require biopsy, enhancing the accuracy of tissue sampling.

2. Procedure

The procedure associated with CPT® Code 76098 involves several critical steps that ensure the effective examination of the surgical specimen. Each step is designed to maximize the accuracy and utility of the radiological assessment.

  • Step 1: Specimen Preparation The surgical specimen is first prepared for examination. This may involve ensuring that the specimen is properly oriented and marked, which is essential for accurate radiological assessment.
  • Step 2: Radiological Imaging The pathologist then performs a radiological examination of the specimen. This imaging allows for visualization of the internal structures of the specimen, which is crucial for identifying areas of interest, such as tumor margins and other significant features.
  • Step 3: Localization of Target Areas Following the imaging, the pathologist uses the radiographic findings to localize specific areas within the specimen that require further investigation. This step is vital for ensuring that the most relevant tissue samples are obtained for microscopic examination.
  • Step 4: Tissue Sampling Once the target areas are identified, the pathologist proceeds to obtain tissue samples from these localized regions. These samples are then prepared for microscopic examination, which is the final step in the diagnostic process.

3. Post-Procedure

After the radiological examination and subsequent tissue sampling, the pathologist will typically prepare the obtained samples for microscopic analysis. This may involve processing the tissue to create slides that can be examined under a microscope. The results of this examination will provide critical information regarding the nature of the specimen, including the presence of malignancy, tumor margins, and other pathological features. The pathologist may also document findings and communicate results to the referring physician, which is essential for guiding further treatment decisions. Additionally, proper handling and storage of the specimen and samples are crucial to maintain their integrity for accurate analysis.

Short Descr X-RAY EXAM SURGICAL SPECIMEN
Medium Descr RADIOLOGICAL EXAMINATION SURGICAL SPECIMEN
Long Descr Radiological examination, surgical specimen
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator T-Packaged Codes
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 4 - Diagnostic Radiology
Berenson-Eggers TOS (BETOS) I1C - Standard imaging - breast
MUE 3
CCS Clinical Classification 226 - Other diagnostic radiology and related techniques
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
GC This service has been performed in part by a resident under the direction of a teaching physician
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
CR Catastrophe/disaster related
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
FY X-ray taken using computed radiography technology/cassette-based imaging
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
56 Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
SG Ambulatory surgical center (asc) facility service
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
Date
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2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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