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Official Description

Level I - Surgical pathology, gross examination only

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 88300 refers to a Level I surgical pathology service that involves the gross examination of tissue specimens. This procedure is typically performed on tissue that has been removed during various surgical interventions, including biopsies, excisions, or resections. The term "gross examination" indicates that the pathologist evaluates the tissue with the naked eye, assessing its overall characteristics, size, shape, and any visible abnormalities without the use of a microscope. This initial assessment is crucial as it helps in determining the next steps in the diagnostic process, including whether further microscopic examination is necessary. The gross examination serves as a foundational component of surgical pathology, providing essential information that can influence patient management and treatment decisions.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 88300 is indicated for the examination of tissue specimens that have been surgically removed. The following conditions may warrant this examination:

  • Biopsy Tissue samples taken to investigate the presence of disease, such as cancer or infection.
  • Excision Removal of a lesion or abnormal tissue for diagnostic purposes.
  • Resection Surgical removal of a portion of an organ or structure, often to treat or diagnose a disease.

2. Procedure

The procedure for CPT® Code 88300 involves several key steps that ensure a thorough gross examination of the tissue specimen:

  • Step 1: Receipt of Specimen Upon receipt, the tissue specimen is carefully labeled and documented to ensure accurate tracking and identification throughout the examination process.
  • Step 2: Visual Inspection The pathologist conducts a detailed visual inspection of the specimen, noting its size, shape, color, and any visible abnormalities. This step is critical for identifying potential areas of concern that may require further analysis.
  • Step 3: Description and Documentation The findings from the visual inspection are meticulously documented, including any notable features of the tissue. This documentation serves as a record of the gross examination and may inform subsequent microscopic evaluation if necessary.
  • Step 4: Preparation for Further Analysis If indicated, the specimen may be prepared for microscopic examination, which involves slicing the tissue into thin sections and placing them on slides for further evaluation.

3. Post-Procedure

After the gross examination is completed, the pathologist may provide a preliminary report based on the findings. If further microscopic analysis is warranted, the tissue will be processed accordingly. The expected recovery from the surgical procedure that provided the tissue specimen will depend on the specific surgical intervention performed. Additionally, the pathologist's findings may lead to further diagnostic testing or treatment recommendations based on the characteristics of the examined tissue.

Short Descr SURGICAL PATH GROSS
Medium Descr LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY
Long Descr Level I - Surgical pathology, gross examination only
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 STV-Packaged Codes
Type of Service (TOS) 5 - Diagnostic Laboratory
Berenson-Eggers TOS (BETOS) T1G - Lab tests - other (Medicare fee schedule)
MUE 4
CCS Clinical Classification 234 - Pathology
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.
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.
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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
GC This service has been performed in part by a resident under the direction of a teaching physician
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
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
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
90 Reference (outside) laboratory: when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
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.
91 Repeat clinical diagnostic laboratory test: in the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. note: this modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. this modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). this modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
GW Service not related to the hospice patient's terminal condition
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GB Claim being re-submitted for payment because it is no longer covered under a global payment demonstration
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
LT Left side (used to identify procedures performed on the left side of the body)
PC Wrong surgery or other invasive procedure on patient
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q5 Service furnished under a reciprocal billing 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
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
QW Clia waived test
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
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2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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