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The CPT® Code 88307 refers to a Level V 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, particularly in identifying malignancies. The process begins with the removal of tissue through procedures such as biopsies, excisions, or resections. Once the tissue is obtained, it is transported from the surgical suite to a pathologist for analysis. The pathologist first conducts a gross examination, visually inspecting the specimen to note any significant characteristics that may indicate the nature of the tissue. Following this initial assessment, the specimen is prepared for microscopic evaluation, where the pathologist examines the cellular structure in detail. This thorough analysis aids in establishing a definitive diagnosis, determining the presence or absence of cancer, and identifying the specific type of malignancy if cancerous cells are present. Additionally, the examination includes assessing the surgical margins to ensure that the entire diseased area has been excised. After completing the evaluation, the pathologist prepares a detailed written report of the findings, which is then sent to the treating physician. The coding for pathology services, including Level V examinations, is based on various factors such as the type of tissue examined, the expected condition of the tissue, 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 III (CPT® Code 88304), Level IV (CPT® Code 88305), and Level VI (CPT® Code 88309).
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The Level V surgical pathology examination (CPT® Code 88307) is indicated for a variety of surgical specimens that require thorough evaluation to diagnose conditions accurately. The following are specific indications for this procedure:
The procedure for a Level V surgical pathology examination (CPT® Code 88307) involves several critical steps to ensure accurate diagnosis and evaluation of the tissue specimen. The following outlines the procedural steps:
Following the Level V surgical pathology examination, the pathologist's findings are communicated to the treating physician, who will use this information to guide further patient management. The report may indicate the need for additional diagnostic tests, treatment options, or follow-up procedures based on the results. It is essential for the physician to review the report thoroughly to ensure that any necessary actions are taken promptly. Additionally, the pathologist may be available for consultation to discuss the findings and their implications for patient care. The patient may also be monitored for any symptoms or complications related to the original condition that necessitated the surgical procedure.
| Short Descr | TISSUE EXAM BY PATHOLOGIST | Medium Descr | LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM | Long Descr | Level V - Surgical pathology, gross and microscopic examination Adrenal, resection Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta, third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) - biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse | 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 | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | T1G - Lab tests - other (Medicare fee schedule) | MUE | 8 | CCS Clinical Classification | 234 - Pathology |
This is a primary code that can be used with these additional add-on codes.
| 0754T | Add-on Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for level V, 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 | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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. | CR | Catastrophe/disaster related | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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 | 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. | 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 | 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. | 27 | Multiple outpatient hospital e/m encounters on the same date: for hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct e/m encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department e/m code(s). this modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). note: this modifier is not to be used for physician reporting of multiple e/m services performed by the same physician on the same date. for physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see evaluation and management, emergency department, or preventive medicine services codes. | 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) | F9 | Right hand, fifth digit | GA | Waiver of liability statement issued as required by payer policy, individual case | GT | Via interactive audio and video telecommunication systems | 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) | 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 | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | Q3 | Live kidney donor surgery and related services | 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 | QW | Clia waived test | RT | Right side (used to identify procedures performed on the right side of the body) |
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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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