CPT Codes For Surgical Pathology Procedures

Surgical pathology procedures are used to remove samples of the patient’s tissue during a surgery. The surgical pathology procedures are covered with range CPT 88300 until CPT 88399. The list below consists of the official long descriptions and we added a lay term and a short description for every surgical pathology CPT code.

CPT Code 88300

Lay-term: CPT 88300 typically covers essentially gross examination only for surgical pathology.

Long description: Level I – Surgical pathology, gross examination only.

Short description: Surgical pathology, level I.

CPT Code 88302

Lay-term: CPT 88302 usually includes for surgical pathology, both gross and microscopic examination.

Long description: Level II – including;

• Appendix, incidental
• Fallopian tube, sterilization
• Fingers/toes, amputation, traumatic
• Foreskin, newborn
• Hernia sac, any location
• Hydrocele sac
• Nerve
• Skin, plastic repair
• Sympathetic ganglion
• Testis, castration
• Vaginal mucosa, incidental
• Vas deferens, sterilization

Short description: Surgical pathology, level II.

CPT Code 88304

Lay-term: CPT 88304 generally includes surgical pathology level III, which encompasses gross and microscopic examination.

Long description: Level III – including;

• Abortion, induced
• Abscess
• Aneurysm – arterial/ventricular
• Anus, tag
• Appendix, other than incidental
• Artery, atheromatous plaque
• Bartholin’s gland cyst
• Bone fragment(s), other than pathologic fracture
• Bursa/synovial cyst
• Carpal tunnel tissue
• Cartilage, shavings
• Cholesteatoma
• Colon, colostomy stoma
• Conjunctiva – biopsy/pterygium
• Cornea
• Diverticulum – esophagus/small intestine
• Dupuytren’s contracture tissue
• Femoral head, other than fracture
• Fissure/fistula
• Foreskin, other than newborn
• Gallbladder
• Ganglion cyst
• Hematoma
• Hemorrhoids
• Hydatid of Morgagni
• Intervertebral disc
• Joint, loose body
• Meniscus
• Mucocele, salivary
• Neuroma – Morton’s/traumatic
• Pilonidal cyst/sinus
• Polyps, inflammatory – nasal/sinusoidal
• Skin – cyst/tag/debridement
• Soft tissue, debridement
• Soft tissue, lipoma
• Spermatocele
• Tendon/tendon sheath
• Testicular appendage
• Thrombus or embolus
• Tonsil and/or adenoids
• Varicocele
• Vas deferens, other than sterilization
• Vein, varicosity

Short description: Surgical pathology, level III.

CPT Code 88305

Lay-term: CPT 88305 usually covers surgical pathology level IV, involving both gross and microscopic examination.

Long description: Level IV – including;

• Abortion – spontaneous/missed
• Artery, biopsy
• Bone marrow, biopsy
• Bone exostosis
• Brain/meninges, other than for tumor resection
• Breast, biopsy, not requiring microscopic evaluation of surgical margins
• Breast, reduction mammoplasty
• Bronchus, biopsy
• Cell block, any source
• Cervix, biopsy
• Colon, biopsy
• Duodenum, biopsy
• Endocervix, curettings/biopsy
• Endometrium, curettings/biopsy
• Esophagus, biopsy
• Extremity, amputation, traumatic
• Fallopian tube, biopsy
• Fallopian tube, ectopic pregnancy
• Femoral head, fracture
• Fingers/toes, amputation, non-traumatic
• Gingiva/oral mucosa, biopsy
• Heart valve
• Joint, resection
• Kidney, biopsy
• Larynx, biopsy
• Leiomyoma(s), uterine myomectomy – without uterus
• Lip, biopsy/wedge resection
• Lung, transbronchial biopsy
• Lymph node, biopsy
• Muscle, biopsy
• Nasal mucosa, biopsy
• Nasopharynx/oropharynx, biopsy
• Nerve, biopsy
• Odontogenic/dental cyst
• Omentum, biopsy
• Ovary with or without tube, non-neoplastic
• Ovary, biopsy/wedge resection
• Parathyroid gland
• Peritoneum, biopsy
• Pituitary tumor
• Placenta, other than third trimester
• Pleura/pericardium – biopsy/tissue
• Polyp, cervical/endometrial
• Polyp, colorectal
• Polyp, stomach/small intestine
• Prostate, needle biopsy
• Prostate, TURS
• Salivary gland, biopsy
• Sinus, paranasal biopsy
• Skin, other than cyst/tag/debridement/plastic repair
• Small intestine, biopsy
• Soft tissue, other than tumor/mass/lipoma/debridement
• Spleen
• Stomach, biopsy
• Synovium
• Testis, other than tumor/biopsy/castration
• Thyroglossal duct/brachial cleft cyst
• Tongue, biopsy
• Tonsil, biopsy
• Trachea, biopsy
• Ureter, biopsy
• Urethra, biopsy
• Urinary bladder, biopsy
• Uterus, with or without tubes and ovaries, for prolapse
• Vagina, biopsy
• Vulva/labia, biopsy

Short description: Surgical pathology, level IV.

CPT Code 88307

Lay-term: CPT 88307 is typically billed for surgical pathology level V, which involves gross and microscopic examination.

Long description: Level V – includes ;

• Adrenal, resection
• Bone – biopsy/curettings
• Bone fragment [s], pathologic fracture
• Brain, biopsy
• Brain/meninges, tumor resection
• Breast, excision of lesion, requiring microscopic evaluation of surgical margins
• Breast, mastectomy – partial/ simple
• Cervix, conization
• Colon, segmental resection, other then for tumor
• Extremity, amputation, non- traumatic
• Eye, enucleation
• Kidney, partial/total nephrectomy
• Larynx, partial/total resection
• Liver, biopsy – needle/wedge
• Liver, partial resection
• Lung, wedge biopsy
• Lymph nodes, regional resection
• Mediastinum, mass
• Myocardium, biopsy
• Odontogenic tumor
• Ovary with or without tube, neoplastic
• Pancreas, biopsy
• Placenta, third trimester
• Prostate, except radical resection
• Salivary gland
• Sentinel lymph node
• Small intestine, resection, other than for tumor
• Soft tissue mass (except lipoma) – biopsy/simple excision
• Stomach – subtotal/total resection, other then for a tumor
• Testis, biopsy
• Thymus, tumor
• Thyroid, total/lobe
• Ureter, resection
• Urinary bladder, TUR
• Uterus, with or without tubes and ovaries, other than neoplastic/ prolapse

Short description: Surgical pathology, level V.

CPT Code 88309

Lay-term: CPT 88309 is generally used for surgical pathology level VI, encompassing both gross and microscopic examination.

Long description: Level VI and includes ;

• Bone resection
• Breast, mastectomy – with regional lymph nodes
• Colon, segmental resection for tumor
• Colon, total resection
• Esophagus, partial/total resection
  • Extremity, disarticulation
• Fetus, with dissection
• Larynx, partial /total resection – with regional lymph nodes
• Lung – total/lobe/segment resection
• Pancreas, total/subtotal resection
• Prostate, radical resection
• Small intestine, resection for tumor
• Soft tissue tumor, extensive resection
• Stomach – subtotal/total resection foor tumor
• Testis, tumor
• Tongue/tonsil – resection for tumor
• Urinary bladder, partial/total resection
• Uterus, with or without tubes and ovaries , neoplastic
• Vulva, total/subtotal resection

Short description: Surgical pathology, level VI.

CPT Code 88311

Lay-term: Decalcification procedure, in addition to the code for the surgical pathology examination.

Long description: Decalcification procedure [List separately in addition to the code for surgical pathology examination].

Short description: Decalcification procedure.

CPT Code 88312

Lay-term: You can use CPT 88312 for a Special stain for microorganisms.

Long description: Special stain including intepretation and report; Group I for microorganisms [eg, acid-fast, methenamine silver].

Short description: Special stain for microorganisms.

CPT Code 88313

Lay-term: Utilize CPT 88313 for group II special staining activity excluding microorganism stains, enzyme constituents stains or immunocytochemistry and immunohistochemistry.

Long description: Special stain including interpretation and report; Group II, all other [eg, iron, trichrome], except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.

Short description: Group II special stains activity.

CPT Code 88314

Lay-term: Apply the CPT 88314 code for histochemically stained frozen tissue block.

Long description: Special stain including interpretation and report; histochemical stain on frozen tissue block [List separately in addition to the code for the primary procedure].

Short description: Histochemical stained frozen tissue.

CPT Code 88315

Lay-term: CPT 88315 may be used when carrying out special staining for microorganisms, like acid-fast and methenamine silver.

Long description: Special stains, group I for microorganisms [e.g., acid-fast, methenamine silver].

Short description: Special staining for microorganisms.

CPT Code 88316

Lay-term: You can use CPT 88316 for special staining task, excluding some specific staining practices.

Long description: Special stains, group II, all other [eg, iron, trichrome], except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.

Short description: Group II special staining.

CPT Code 88317

Lay-term: CPT 88317 is to be used when staining for enzyme constituents.

Long description: Special stains, group III, for enzyme constituents.

Short description: Staining for enzyme constituents.

CPT Code 88318

Lay-term: CPT 88318 can be billed for special staining of microorganisms.

Long description: Special stains, group IV, for microorganisms [eg, trichrome, methenamine silver].

Short description: Staining for microorganisms.

CPT Code 88318

Lay-term: CPT 88318 is used for special staining of microorganisms.

Long description: Special stains, group IV, for microorganisms [eg, trichrome, methenamine silver].

Short description: Staining for microorganisms.

CPT Code 88319

Lay-term: CPT 88319 can be used for special stains of carbohydrates, mucopolysaccharides, glycoproteins, lipids, and basement membranes.

Long description: Special stains, group V, for carbohydrates, mucopolysaccharides, glycoproteins, lipids, and basement membranes.

Short description: Staining for carbohydrates, mucopolysaccharides, glycoproteins, lipids, and basement membranes.

CPT Code 88321

Lay-term: CPT 88321 refers to a decalcification procedure used in addition to the surgical pathology examination.

Long description: Decalcification procedure [List separately in addition to the code for surgical pathology examination].

Short description: Decalcification procedure.

CPT Code 88323

Lay-term: CPT 88323 involves the consultation and reporting on slides prepared elsewhere.

Long description: Consultation and report on referred slides prepared elsewhere.

Short description: Consultation and report on referred slides.

CPT Code 88323

Lay-term: Use this CPT code when giving a consultation and compiling a report on slides prepared in a different location.

Long description: Consultation and report on referred slides prepared elsewhere.

Short description: Consultation and report on referred slides.

CPT Code 88325

Lay-term: CPT 88325 is used upon performing an initial single antibody stain procedure via immunohistochemistry or immunocytochemistry.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure.

Short description: Single antibody staining procedure.

CPT Code 88326

Lay-term: Apply the CPT 88326 when you are performing any additional single antibody stain procedures.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure [List separately in addition to the code for the primary procedure].

Short description: Additional single antibody staining.

CPT Code 88327

Lay-term: CPT 88327 is the code for the initial multiple antibody stain procedure done per specimen.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; initial multiple antibody stain procedure.

Short description: Initial multiple antibody staining.

CPT Code 88328

Lay-term: You use this CPT code for any subsequent multiple antibody staining conducted per specimen.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; each additional multiple antibody stain procedure [List separately in addition to the code for the primary procedure].

Short description: Additional multiple antibody staining.

CPT Code 88329

Lay-term: CPT 88329 is the CPT code for morphometric analysis of tumor immunohistochemistry.

Long description: Morphometric analysis, tumor immunohistochemistry [eg, Her-2/Neu, estrogen receptor/progesterone receptor], quantitative or semiquantitative, each antibody; manual.

Short description: Analysis of tumor immunohistochemistry.

CPT Code 88331

Lay-term: CPT 88331 is used as an add-on code for decalcification procedure done in addition to the surgical pathology examination.

Long description: Decalcification procedure [List separately in addition to the code for surgical pathology examination].

Short description: Decalcification procedure.

CPT Code 88332

Lay-term: CPT 88332 can be used when staining for a single antibody is done on a specimen.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure.

Short description: Single antibody staining.

CPT Code 88333

Lay-term: CPT 88333 should be billed for each additional single antibody stain procedure.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure [List separately in addition to the code for the primary procedure].

Short description: Additional single antibody staining.

CPT Code 88334

Lay-term: CPT 88334 applies to initial multiple antibody stain procedure on a specimen.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; initial multiple antibody stain procedure.

Short description: Initial multiple antibody staining.

CPT Code 88335

Lay-term: Bill CPT 88335 for each additional multiple antibody stain procedure.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; each additional multiple antibody stain procedure [List separately in addition to the code for the primary procedure].

Short description: Additional multiple antibody staining.

CPT Code 88342

Lay-term: CPT 88342 can be billed when Group I special stain is used for microorganisms.

Long description: Special stain including interpretation and report; Group I for microorganisms [e.g., acid-fast, methenamine silver].

Short description: Group I special stain for microorganisms.

CPT Code 88346:

Lay-term: CPT 88346 is used for all other Group II special stains, excluding stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.

Long description: Special stain including interpretation and report; Group II, all other [e.g., iron, trichrome], except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.

Short description: Group II special stains, excluding certain stains.

CPT Code 88347:

Lay-term: For histochemical stain on frozen tissue block you can use CPT code 88347.

Long description: Special stain including interpretation and report; histochemical stain on frozen tissue block [List separately in addition to the code for the primary procedure].

Short description: Histochemical stain on frozen tissue.

CPT Code 88348:

Lay-term: CPT 88348 is used for a decalcification procedure.

Long description: Decalcification procedure [List separately in addition to the code for surgical pathology examination].

Short description: Decalcification procedure.

CPT Code 88350:

Lay-term: Use CPT 88350 for an initial single antibody stain.

Long description: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure.

Short description: Initial single antibody stain procedure.

CPT Code 88360

Lay-term: CPT 88360 is used for special stains of group I microorganisms.

Long description: Special stains, group I for microorganisms [eg, acid-fast, methenamine silver].

Short description: Group I microorganisms’ special stains.

CPT Code 88361

Lay-term: You can use CPT 88361 for special stains of group II without microorganisms, enzyme constituents, or immunocytochemistry.

Long description: Special stains, group II, all other [eg, iron, trichrome], except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.

Short description: Group II special stains.

CPT Code 88362

Lay-term: For special enzyme constituent stains of group III use CPT 88362.

Long description: Special stains, group III, for enzyme constituents.

Short description: Enzyme constituents’ special stains.

CPT Code 88363

Lay-term: Use CPT 88363 for special stains of group IV microorganisms.

Long description: Special stains, group IV, for microorganisms [eg, trichrome, methenamine silver].

Short description: Group IV microorganisms’ special stains.

CPT Code 88365

Lay-term: For special stains of carbohydrates, mucopolysaccharides, glycoproteins, lipids, and basement membranes, use CPT 88365.

Long description: Special stains, group V, for carbohydrates, mucopolysaccharides, glycoproteins, lipids, and basement membranes.

Short description: Special stains for carbohydrates, etc.

CPT Code 88399

Lay-term: CPT 88399 is used for an unlisted special stain procedure.

Long description: Unlisted special stain procedure [List separately in addition to the code for the primary procedure].

Short description: Unlisted special stain procedure.

Sources

https://www.aapc.com/codes/cpt-codes-range/88300-88399/

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P00967