Case2Code

Official Description

Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure)

Common Language Description

The CPT® Code 88388 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, which may involve fixing the tissue using chemical agents like aldehydes or alcohols, or alternatively, freezing the tissue 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 molecular studies are crucial for diagnosing various conditions, including genetic disorders and malignant neoplasms, as they help identify specific genetic mutations associated with these diseases. After the completion of the analytical studies, the physician interprets the results and compiles a written report detailing the findings. It is important to note that CPT® Code 88388 is used when the tissue preparation is performed in conjunction with other procedures, such as a touch imprint, intraoperative consultation, or frozen section, and should be listed separately in addition to the code for the primary procedure.

1. Indications

The procedure associated with CPT® Code 88388 is indicated for various clinical scenarios where detailed analysis of tissue samples is necessary. These indications include:

Genetic Disorders The procedure is performed on individuals suspected of having genetic mutations that may lead to specific diseases.
Malignant Neoplasms It is indicated for the evaluation of tissue samples from patients with suspected or diagnosed cancers, allowing for the identification of genetic alterations associated with malignancies.
Diagnostic Confirmation The procedure aids in confirming diagnoses based on the characteristics of the tissue sample, which may be critical for determining appropriate treatment plans.

2. Procedure

The procedure for CPT® Code 88388 involves several key steps that ensure the proper preparation of tissue for non-microscopic analytical studies. These steps include:

Macroscopic Examination Initially, the tissue sample undergoes a thorough visual examination. During this step, the pathologist notes any definitive characteristics of the tissue, which may include size, shape, color, and texture. This examination is crucial for assessing the sample's suitability for further analysis.
Dissection Following the macroscopic examination, the tissue is carefully dissected. This process allows for a more detailed evaluation of the internal structure of the tissue, which is essential for understanding its composition and any pathological changes that may be present.
Tissue Preparation After dissection, the tissue is prepared for analysis. This preparation may involve fixing the tissue using chemical agents such as aldehydes or alcohols, which preserve the cellular structure. Alternatively, the tissue may be frozen to maintain its integrity. The choice of preparation method depends on the specific requirements of the subsequent analytical studies.
Embedding Once the tissue is prepared, it is embedded in a medium, typically paraffin or resin. This embedding process is vital as it allows the tissue to be sliced into thin sections, which are necessary for detailed analysis in non-microscopic studies.
Slicing The embedded tissue is then sliced into thin sections using a microtome. These sections are essential for conducting the nucleic acid-based molecular studies, as they provide the necessary samples for analysis.

3. Post-Procedure

After the completion of the tissue preparation and analysis, the physician interprets the results obtained from the molecular studies. This interpretation is critical for diagnosing any underlying conditions and determining the appropriate course of treatment. The physician will compile a written report detailing the findings of the analysis, which may include information on genetic mutations or other significant characteristics of the tissue. It is important for healthcare providers to ensure that the results are communicated effectively to the patient and incorporated into their overall treatment plan. Additionally, proper documentation of the procedure and findings is essential for compliance and billing purposes.

Short Descr	TISS EX MOLECUL STUDY ADD-ON
Medium Descr	MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE
Long Descr	Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure)
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	Not applicable/unspecified.
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.
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service