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The CPT® Code 88304 refers to a Level III surgical pathology examination, which involves both gross and microscopic evaluation of tissue specimens removed during surgical procedures. This examination is critical for diagnosing various conditions, as it allows pathologists to assess the characteristics of the tissue visually before preparing it for microscopic analysis. The process begins with the transportation of the specimen from the surgical suite to the pathology lab, where the pathologist conducts a thorough visual examination to identify any notable features. Following this initial assessment, the specimen undergoes preparation for microscopic evaluation, enabling the pathologist to analyze the cellular structure in detail. This analysis is essential for establishing a diagnosis, determining the presence or absence of malignant neoplasms, identifying the specific type of malignancy if present, and evaluating the margins of the specimen to confirm whether the entire diseased area has been excised. After completing the examination, the pathologist prepares a comprehensive written report of the findings, which is then sent to the treating physician. The coding for pathology services, including Level III examinations, is based on several factors, including the type of tissue examined, the expected condition of the tissue (normal or diseased), the complexity of the examination, and the time required to complete the analysis. For reference, other levels of pathology examinations include Level II (CPT® Code 88302), Level IV (CPT® Code 88305), Level V (CPT® Code 88307), and Level VI (CPT® Code 88309).
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The Level III surgical pathology examination (CPT® Code 88304) is indicated for a variety of conditions and procedures where tissue analysis is necessary. The following are specific indications for performing this examination:
The Level III surgical pathology examination involves several procedural steps that ensure a thorough evaluation of the tissue specimen. The following steps outline the process:
Following the Level III surgical pathology examination, the pathologist's report is crucial for guiding the treating physician's next steps in patient management. The report may indicate the need for further diagnostic testing, treatment options, or monitoring based on the findings. It is essential for the physician to review the report thoroughly to understand the implications of the pathology results. Additionally, the patient may require follow-up appointments to discuss the findings and any necessary interventions. The recovery process for the patient will depend on the initial surgical procedure performed and the specific diagnosis made from the pathology examination.
| Short Descr | TISSUE EXAM BY PATHOLOGIST | Medium Descr | LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM | Long Descr | Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma - Morton's/traumatic Pilonidal cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity | 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 | 5 | CCS Clinical Classification | 234 - Pathology |
This is a primary code that can be used with these additional add-on codes.
| 0752T | Add-on Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for level III, 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. | 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 | 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 | 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 | TA | Left foot, great toe | T1 | Left foot, second digit | T5 | Right foot, great toe | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | T6 | Right foot, second digit | 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 | T4 | Left foot, fifth digit | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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.) | 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. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | E1 | Upper left, eyelid | E4 | Lower right, eyelid | FS | Split (or shared) evaluation and management visit | G0 | Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke | GA | Waiver of liability statement issued as required by payer policy, individual case | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | PC | Wrong surgery or other invasive procedure on patient | 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 | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | 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 | 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) | RT | Right side (used to identify procedures performed on the right side of the body) | SA | Nurse practitioner rendering service in collaboration with a physician | SG | Ambulatory surgical center (asc) facility service | T2 | Left foot, third digit | T3 | Left foot, fourth digit | T7 | Right foot, third digit | T8 | Right foot, fourth digit | T9 | Right foot, fifth digit | X3 | Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital | 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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| 2013-01-01 | Changed | Description Changed |
| 2009-01-01 | Changed | Code description changed. |
| 2008-01-01 | 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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