How To Use CPT Code 88300

CPT 88300 describes the level I examination of a surgical pathology specimen performed by a physician, typically a pathologist. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88300?

CPT 88300 can be used to describe the level I examination of a surgical pathology specimen performed by a physician, usually a pathologist. This code is used when the physician receives a surgical pathology specimen, assigns an accession number to each specimen vial or specimen, performs a gross examination of the specimen, and prepares a detailed report that may include a diagnosis.

2. Official Description

The official description of CPT code 88300 is: ‘Level I – Surgical pathology, gross examination only.’

3. Procedure

1. The physician receives a surgical pathology specimen and assigns an accession number to each specimen vial or specimen.
2. The physician performs a gross examination of the specimen, which involves reviewing features observed without a microscope, such as the color and shape.
3. The physician prepares a detailed report for each specimen, which may include a diagnosis.

4. Qualifying circumstances

CPT 88300 is used when a physician performs a level I examination of a surgical pathology specimen. This code applies to cases where the physician receives a specimen, assigns an accession number, performs a gross examination, and prepares a detailed report. It is important to note that CPT 88300 is specific to the gross examination only and does not involve microscopic evaluation of the tissue.

5. When to use CPT code 88300

CPT code 88300 should be used when a physician performs a level I examination of a surgical pathology specimen, focusing solely on the gross examination. This code is appropriate when there is no need for microscopic evaluation of the tissue. If the examination involves both gross and microscopic evaluation, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 88300, the physician must document the following information:

• Accession number assigned to each specimen vial or specimen
• Gross features observed during the examination, such as color and shape
• Detailed report for each specimen, including any diagnosis

7. Billing guidelines

When billing for CPT 88300, ensure that the physician performs a level I examination of a surgical pathology specimen, focusing solely on the gross examination. This code should not be reported if the examination involves microscopic evaluation or if a different CPT code is more appropriate based on the specific circumstances of the case.

8. Historical information

CPT 88300 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A pathologist performs a level I examination of a surgical pathology specimen, reviewing the gross features and preparing a detailed report.
2. A physician receives a biopsy specimen, assigns an accession number, performs a gross examination, and provides a report for the specimen.
3. A pathologist examines a tissue sample, documenting the gross features observed and providing a diagnosis based on the examination.
4. A surgeon sends a specimen to a pathologist for a level I examination, focusing on the gross examination and reporting the findings.
5. A pathologist reviews the gross features of a surgical pathology specimen, prepares a detailed report, and assigns an accession number to each specimen vial or specimen.
6. A physician performs a level I examination of a surgical pathology specimen, documenting the gross features observed and providing a report for each specimen.
7. A pathologist receives a specimen, performs a gross examination, and prepares a detailed report for each specimen, including any diagnosis.
8. A surgeon sends a tissue sample to a pathologist for a level I examination, focusing on the gross examination and receiving a detailed report for the specimen.
9. A pathologist examines a biopsy specimen, assigns an accession number, performs a gross examination, and provides a report for the specimen.
10. A physician performs a level I examination of a surgical pathology specimen, documenting the gross features observed and preparing a detailed report for each specimen.