CPT 88305 can be used to report a level IV examination of a surgical pathology specimen. This procedure includes accessioning the specimen, performing a gross and microscopic examination, and reporting findings.
What Is CPT Code 88305?
CPT code 88305 describes a level IV examination of a surgical pathology specimen performed by a physician, typically a pathologist.
This type of examination includes four steps:
- Accessioning the specimen into the lab: This involves formally receiving the specimen and preparing it for analysis.
- Gross examination: During this phase, the pathologist examines the visible characteristics of the specimen, such as its color, shape, and size, without using a microscope.
- Microscopic examination: In this phase, the pathologist uses a microscope to identify any abnormalities or signs of disease in the specimen.
- Reporting findings: Once the examination is complete, the pathologist prepares a detailed report that includes their findings and may include a diagnosis based on the results of the gross and microscopic exams.
The CPT book describes CPT code 88305 as: “Level IV – Surgical pathology, gross and microscopic examinationAbortion – spontaneous/missedArtery, biopsyBone marrow, biopsyBone exostosisBrain/meninges, other than for tumor resectionBreast, biopsy, not requiring microscopic evaluation of surgical marginsBreast, reduction mammoplastyBronchus, biopsyCell block, any sourceCervix, biopsyColon, biopsyDuodenum, biopsyEndocervix, curettings/biopsyEndometrium, curettings/biopsyEsophagus, biopsyExtremity, amputation, traumaticFallopian tube, biopsyFallopian tube, ectopic pregnancyFemoral head, fractureFingers/toes, amputation, non-traumaticGingiva/oral mucosa, biopsyHeart valveJoint, resectionKidney, biopsyLarynx, biopsyLeiomyoma(s), uterine myomectomy – without uterusLip, biopsy/wedge resectionLung, transbronchial biopsyLymph node, biopsyMuscle, biopsyNasal mucosa, biopsyNasopharynx/oropharynx, biopsyNerve, biopsyOdontogenic/dental cystOmentum, biopsyOvary with or without tube, non-neoplasticOvary, biopsy/wedge resectionParathyroid glandPeritoneum, biopsyPituitary tumorPlacenta, other than third trimesterPleura/pericardium – biopsy/tissuePolyp, cervical/endometrialPolyp, colorectalPolyp, stomach/small intestineProstate, needle biopsyProstate, TURSalivary gland, biopsySinus, paranasal biopsySkin, other than cyst/tag/debridement/plastic repairSmall intestine, biopsySoft tissue, other than tumor/mass/lipoma/debridementSpleenStomach, biopsySynoviumTestis, other than tumor/biopsy/castrationThyroglossal duct/brachial cleft cystTongue, biopsyTonsil, biopsyTrachea, biopsyUreter, biopsyUrethra, biopsyUrinary bladder, biopsyUterus, with or without tubes and ovaries, for prolapseVagina, biopsyVulva/labia, biopsy.”
The physician is responsible for examining surgical pathology specimens, such as biopsies taken from various body parts such as the bone marrow, esophagus, or muscle. This process begins by assigning each vial or specimen a unique accession number.
The physician then performs a gross examination, during which they review the specimen’s features without using a microscope. This includes examining the color, shape, and any other visible characteristics of the specimen.
In addition to the gross examination, the physician also performs a microscopic examination to identify any abnormalities or signs of disease present in the specimen.
Once both examinations have been completed, the physician prepares a detailed report for each specimen, which may include a diagnosis based on the findings of the gross and microscopic exams.
For a level IV examination, it is essential to ensure that all necessary steps have been taken and all relevant information has been included in the report.
How To Use CPT 88305
CPT code 88305 is used to report the examination of glass microscope slides that have been digitized.
88305 is one of the codes used to report different levels of work a pathologist performs in examining surgical pathology specimens. You can also use CPT 88300, CPT 88302, CPT 88304, CPT 88307, and CPT 88309.
The codes in this range represent increasing work required, with 88300 representing the lowest level (gross examination only) and 88309 representing the highest level (mastectomy with regional lymph nodes).
When choosing the appropriate code, it is vital to consider the specific features of the specimen being examined, such as the presence or absence of lymph tissue, the extent of the resection, and whether or not the surgical margins need to be evaluated microscopically.
To accurately assign a surgical pathology code, the pathologist should provide information about the diagnosis and a specimen description.
For example, a breast biopsy that does not require evaluation of the surgical margins should be reported using code CPT 88305, while a lumpectomy that does require assessment of the surgical margins should be reported using CPT code 88307.
When the pathologist examines a specimen not explicitly listed in the codes, the code that best represents the work required should be chosen by comparing it to the documented specimens.
It is important to note that it is never appropriate to upcode a listed specimen (i.e., choose a code that represents a higher level of work) simply because the work required was more than usual.
You can use CPT 0754T with CPT 88307 when the digitization of glass microscope slides is performed.