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Official Description

Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies), each tissue preparation (eg, a single lymph node)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 88387 refers to the macroscopic examination, dissection, and preparation of tissue specifically for non-microscopic analytical studies, such as nucleic acid-based molecular studies. This procedure involves a thorough visual examination of the tissue sample, where definitive characteristics are noted to assess the sample's quality and relevance. Following this examination, the tissue undergoes dissection, which allows for a more detailed evaluation of its structure and composition. The preparation of the tissue is a critical step, where it can be fixed using either an aldehyde or alcohol fixator, or alternatively, it may be frozen to preserve its integrity for further analysis. Once prepared, the tissue is embedded in a medium such as paraffin or resin, which facilitates the slicing of the tissue into thin sections. These sections are essential for conducting non-microscopic analytical studies, particularly those that focus on nucleic acids. Such studies are often performed on patients with specific diseases that may be linked to genetic mutations, as well as on malignant neoplasms. The range of molecular studies that can be conducted is broad and is determined by the patient's diagnosis or the suspected disease. After the analytical studies are completed, the physician interprets the results and compiles a written report detailing the findings, which is crucial for guiding further clinical decisions and treatment options.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 88387 is indicated for various clinical scenarios where detailed analysis of tissue samples is necessary. The following conditions may warrant this procedure:

  • Genetic Mutations The procedure is performed on individuals suspected of having diseases caused by genetic mutations, allowing for the identification of specific genetic alterations.
  • Malignant Neoplasms Tissue samples from patients with malignant neoplasms are analyzed to understand the genetic basis of the cancer and to guide treatment decisions.
  • Diagnostic Evaluation The procedure is utilized in the diagnostic evaluation of various diseases, where molecular studies can provide critical insights into the underlying pathology.

2. Procedure

The procedure for CPT® Code 88387 involves several key steps that ensure the proper preparation of tissue for non-microscopic analytical studies. Each step is crucial for obtaining accurate and reliable results.

  • Visual Examination Initially, the tissue sample undergoes a macroscopic examination where the pathologist visually inspects the tissue. This examination allows for the identification of any notable characteristics, such as size, shape, and color, which are essential for further analysis.
  • Dissection Following the visual examination, the tissue is meticulously dissected. This step involves carefully cutting the tissue to evaluate its internal structure and to isolate specific areas of interest that may be relevant for molecular studies.
  • Tissue Preparation After dissection, the tissue is prepared for analysis. This can involve fixing the tissue using an aldehyde or alcohol fixator to preserve its cellular architecture, or freezing the tissue to maintain its molecular integrity. The choice of preparation method depends on the type of analysis to be performed.
  • Embedding Once prepared, the tissue is embedded in a suitable medium, such as paraffin or resin. This embedding process is critical as it allows the tissue to be sliced into thin sections, which are necessary for detailed analysis.
  • Slicing The embedded tissue is then sliced into thin sections using a microtome. These sections are essential for conducting the non-microscopic analytical studies, as they provide the necessary samples for testing.

3. Post-Procedure

After the completion of the tissue preparation process, the next steps involve conducting the non-microscopic analytical studies, such as nucleic acid-based molecular studies. The results of these studies are interpreted by the physician, who then compiles a comprehensive written report detailing the findings. This report is crucial for informing further clinical decisions and treatment plans. Additionally, it is important to ensure that all documentation related to the procedure is accurately maintained for compliance and billing purposes.

Short Descr MACROSCOPIC XM DSJ&PREP TISS
Medium Descr MACROSCOPIC XM DSJ&PREPJ TISS NONMCRSCP STD EA
Long Descr Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies), each tissue preparation (eg, a single lymph node)
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 Items and Services Packaged into APC Rates
Type of Service (TOS) 5 - Diagnostic Laboratory
Berenson-Eggers TOS (BETOS) M5A - Specialist - pathology (HCPCS moved to T1G in 2003)
MUE 2
CCS Clinical Classification 234 - Pathology
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.
GZ Item or service expected to be denied as not reasonable and necessary
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
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
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
Date
Action
Notes
2025-01-01 Changed Short, Medium, and Long Descriptions changed.
2010-01-01 Added -
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Description
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