How To Use CPT Code 88331

CPT 88331 describes the pathology consultation during surgery, specifically the examination of the first tissue block with frozen section(s) of a single specimen. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88331?

CPT 88331 can be used to describe the pathology consultation during surgery, specifically the examination of the first tissue block with frozen section(s) of a single specimen. This code is used when a pathologist consultant provides necessary information about a given specimen to aid the surgeon in making decisions during the surgical procedure.

2. Official Description

The official description of CPT code 88331 is: ‘Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen.’

3. Procedure

1. A pathologist consultant attends the surgical procedure and provides necessary information about a given specimen to aid the surgeon in making decisions during the surgery.
2. Specimens are obtained during the surgery, and frozen sections are prepared for further diagnostic studies.
3. The pathologist examines the first tissue block with frozen section(s) of a single specimen.
4. The pathologist provides a report based on the examination, which helps guide the surgeon in deciding whether to proceed further with the surgical procedure.

4. Qualifying circumstances

CPT 88331 is used when a pathologist consultant examines the first tissue block with frozen section(s) of a single specimen during surgery. This consultation is necessary to provide precise information about the specimen, aiding the surgeon in making decisions during the surgical procedure.

5. When to use CPT code 88331

CPT code 88331 should be used when a pathologist consultant examines the first tissue block with frozen section(s) of a single specimen during surgery. It is important to note that this code is specific to the examination of the first tissue block and does not cover additional blocks examined.

6. Documentation requirements

To support a claim for CPT 88331, the documentation must include the following:

• Diagnoses supporting the medical necessity of the test during surgery
• Documentation supporting that the test is reasonable and necessary for the diagnoses
• Retention of information such as history and physical, examination notes, and the order for the test by the ordering physician/practitioner
• Performance of services as indicated by current medical literature and/or standards of practice

7. Billing guidelines

When billing for CPT 88331, ensure that the examination of the first tissue block with frozen section(s) of a single specimen is performed during surgery. It is important to follow the guidelines for documentation and medical necessity. Additionally, report CPT 88332 for each additional block examined.

8. Historical information

CPT 88331 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 consultant examines the first tissue block with frozen section(s) of a single specimen during surgery to provide necessary information for the surgeon’s decision-making process.
2. During a surgical procedure, a pathologist examines the first tissue block with frozen section(s) of a single specimen to determine the nature of the specimen.
3. A surgeon consults a pathologist who examines the first tissue block with frozen section(s) of a single specimen to provide crucial information for the surgical procedure.
4. Pathology consultation during surgery involves the examination of the first tissue block with frozen section(s) of a single specimen to aid the surgeon in making informed decisions.
5. A pathologist consultant attends a surgical procedure and examines the first tissue block with frozen section(s) of a single specimen to provide valuable insights for the surgeon.
6. During surgery, a pathologist examines the first tissue block with frozen section(s) of a single specimen to assist the surgeon in determining the appropriate course of action.
7. A surgeon seeks a pathology consultation during surgery, and a pathologist examines the first tissue block with frozen section(s) of a single specimen to provide essential information.
8. Pathology consultation during surgery involves the examination of the first tissue block with frozen section(s) of a single specimen to support the surgeon’s decision-making process.
9. A pathologist consultant examines the first tissue block with frozen section(s) of a single specimen during surgery to provide critical insights for the surgical team.
10. During a surgical procedure, a pathologist examines the first tissue block with frozen section(s) of a single specimen to aid in the surgical decision-making process.