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The CPT® Code 88302 refers to a Level II surgical pathology service that involves both gross and microscopic examination of tissue specimens. This procedure is essential for the evaluation of various types of tissues that may be removed during surgical interventions, such as biopsies, excisions, or resections. The process begins with the collection of tissue, which is then transported from the surgical suite to a pathologist for analysis. The pathologist conducts a gross examination, visually inspecting the specimen to identify any notable characteristics that may indicate the presence of disease. Following this initial assessment, the specimen is prepared for microscopic evaluation, allowing for a detailed examination of the cellular structure. This step is crucial for establishing a diagnosis, determining the presence or absence of malignant neoplasms, and identifying the specific type of malignancy if one is present. Additionally, the pathologist assesses the margins of the specimen to confirm whether the entire diseased area has been excised. After completing the examination, a comprehensive written report detailing the findings is generated and sent to the treating physician. The coding for pathology services, including 88302, is determined by factors such as the type of tissue examined, the expected condition of the tissue (normal or diseased), the complexity of the examination, and the time required to perform the analysis. For more advanced levels of pathology examinations, other codes such as 88304, 88305, 88307, and 88309 are utilized, each corresponding to different levels of service complexity.
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The procedure associated with CPT® Code 88302 is indicated for the examination of various tissue types that may be removed during surgical procedures. The following conditions or situations warrant this level of surgical pathology examination:
The procedure for CPT® Code 88302 involves several critical steps that ensure a thorough examination of the tissue specimen. The following outlines the procedural steps:
After the completion of the pathology examination associated with CPT® Code 88302, the pathologist prepares a detailed report of the findings. This report is crucial for the treating physician, as it provides essential information regarding the diagnosis and the nature of the tissue examined. The physician may use this information to guide further treatment decisions or interventions. There are typically no specific post-procedure care requirements for the pathology examination itself, as it is a laboratory-based service. However, the patient may need to follow up with their physician to discuss the results and any necessary next steps based on the findings of the pathology report.
| Short Descr | TISSUE EXAM BY PATHOLOGIST | Medium Descr | LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM | Long Descr | Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization | 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 |
This is a primary code that can be used with these additional add-on codes.
| 0751T | Add-on Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for level II, surgical pathology, gross and microscopic examination (List separately in addition to code for primary procedure) | 88311 | Addon Code MPFS Status: Active Code APC N PUB 100 CPT Assistant Article Decalcification procedure (List separately in addition to code for surgical pathology examination) | 88314 | Addon Code MPFS Status: Active Code APC N PUB 100 CPT Assistant Article Special stain including interpretation and report; histochemical stain on frozen tissue block (List separately in addition to code for primary procedure) |
| 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. | 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 | 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 | 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. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | 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 | 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. | 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. | 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.) | 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. | 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. | FP | Service provided as part of family planning program | 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 | KX | Requirements specified in the medical policy have been met | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q3 | Live kidney donor surgery and related services | RT | Right side (used to identify procedures performed on the right side of the body) | T3 | Left foot, fourth digit | U1 | Medicaid level of care 1, as defined by each state | U2 | Medicaid level of care 2, as defined by each state | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2013-01-01 | Changed | Description Changed |
| 2009-01-01 | Changed | Code description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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