© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 88329 refers to a pathology consultation that occurs during a surgical procedure. This service is specifically requested by the surgeon and involves the examination of a tissue block to ascertain the presence or absence of disease, including malignancy. The primary goal of this consultation is to provide immediate information that can influence surgical decisions, particularly regarding the adequacy of surgical margins. A tissue block is defined as a sample of tissue that has been prepared and submitted as a single specimen for pathological examination. The process begins with a gross examination of the tissue block, which allows the pathologist to assess the overall characteristics of the specimen. Following this initial assessment, the tissue block is subjected to a process known as flash freezing, which preserves the cellular structure for further analysis. The frozen tissue is then sliced into thin sections, enabling detailed microscopic examination. During this evaluation, the pathologist is tasked with identifying any neoplasms or other diseases present, determining the extent of involvement, and assessing whether the surgical margins are free of disease. An initial verbal report is provided to the surgical team, summarizing critical findings such as the presence of neoplasm, the extent of disease involvement, and any other significant characteristics of the tissue sample. Additionally, a comprehensive written report is generated and included in the patient's medical record, ensuring that all findings are documented for future reference. It is important to note that CPT® Code 88329 is specifically for the pathology consultation during surgery without the examination of a tissue block. For the examination of the first tissue block and all frozen sections derived from it, CPT® Code 88331 should be utilized, while CPT® Code 88332 is designated for each additional tissue block with frozen sections.
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The pathology consultation during surgery, represented by CPT® Code 88329, is indicated in various clinical scenarios where immediate pathological assessment is crucial. The following conditions may warrant this procedure:
The procedure for CPT® Code 88329 involves several key steps that ensure a thorough examination of the tissue block during surgery. The following outlines the procedural steps:
After the pathology consultation during surgery, the pathologist's findings are crucial for guiding the surgical team's next steps. The initial verbal report allows for immediate decision-making regarding the surgical approach, such as whether additional tissue needs to be removed or if the procedure can proceed as planned. The written report, which is documented in the medical record, serves as a formal account of the findings and is essential for ongoing patient management and follow-up care. It is important for the surgical team to review the report thoroughly to ensure that all relevant information is considered in the patient's treatment plan. Additionally, any further actions or interventions based on the pathology findings should be documented appropriately in the patient's medical record.
| Short Descr | PATH CONSLTJ DRG SURG | Medium Descr | PATHOLOGY CONSULTATION DURING SURGERY | Long Descr | Pathology consultation during surgery; | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | 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) | 3 - Consultation | Berenson-Eggers TOS (BETOS) | T1G - Lab tests - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 234 - Pathology |
| 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. | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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 | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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 | 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. | 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. | 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. | CR | Catastrophe/disaster related | 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 | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | T2 | Left foot, third digit | UF | Services provided in the morning | 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 | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner |
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| 2024-01-01 | Changed | Short Description changed. |
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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