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The CPT® Code 88331 refers to a pathology consultation that occurs during a surgical procedure, specifically involving the examination of the first tissue block with frozen sections from a single specimen. In this context, a tissue block is a prepared sample of tissue that has been collected and processed for detailed examination by a pathologist. The primary purpose of this consultation is to assist the surgeon in making immediate decisions regarding the surgical procedure by determining the presence or absence of disease, such as malignancy, and assessing whether the surgical margins are free of disease. This is crucial for ensuring that all affected tissue is removed during surgery, which can significantly impact patient outcomes.
During the procedure, the pathologist conducts a gross examination of the tissue block, which involves visually inspecting the sample for any abnormalities. Following this initial assessment, the tissue block is rapidly frozen to preserve its cellular structure, allowing for thin sections to be cut for microscopic examination. The pathologist then examines these frozen sections under a microscope to provide a detailed analysis of the tissue. This includes reporting on the presence of neoplasms or other diseases, the extent of any involvement, and whether the margins of the tissue are clear of disease. The pathologist communicates initial findings verbally to the surgical team, which can influence immediate surgical decisions. Additionally, a comprehensive written report is generated and included in the patient's medical record for future reference. It is important to note that if a pathology consultation occurs without the examination of a tissue block, CPT® Code 88329 should be reported. For any additional tissue blocks with frozen sections, CPT® Code 88332 is utilized.
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The procedure associated with CPT® Code 88331 is indicated in various clinical scenarios where immediate pathological evaluation is necessary during surgery. The following conditions may warrant the use of this code:
The procedure for CPT® Code 88331 involves several critical steps that ensure accurate pathological evaluation during surgery. The following outlines the procedural steps:
After the procedure associated with CPT® Code 88331, 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 need for further surgical intervention. The written report, which is documented in the patient's medical record, serves as a permanent record 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 necessary actions are taken based on the pathologist's recommendations. Additionally, any further tissue blocks that may need examination during the same surgical session should be reported using CPT® Code 88332.
| Short Descr | PATH CONSLTJ SURG 1 BLK 1SPC | Medium Descr | PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1ST SPEC | Long Descr | Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen | 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) | 3 - Consultation | Berenson-Eggers TOS (BETOS) | T1G - Lab tests - other (Medicare fee schedule) | MUE | 11 | CCS Clinical Classification | 234 - Pathology |
This is a primary code that can be used with these additional add-on codes.
| 0841T | Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for pathology consultation during surgery; first tissue block, with frozen section(s), single specimen (List separately in addition to code for primary procedure) | 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) | 88332 | Addon Code MPFS Status: Active Code APC N PUB 100 CPT Assistant Article Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) | 88334 | Addon Code MPFS Status: Active Code APC N PUB 100 CPT Assistant Article Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (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. | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | 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) | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | CR | Catastrophe/disaster related | 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. | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | 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. | 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. | GW | Service not related to the hospice patient's terminal condition | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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.) | 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 | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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. | 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. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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 | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2001-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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