In simple words: An x-ray of the tissue removed during surgery is taken and reviewed by a radiologist to see if the entire abnormal area has been removed. The radiologist quickly tells the surgeon the results so they can remove more tissue if needed.

This code represents a radiological examination of a surgical specimen. The procedure involves imaging the specimen, typically immediately after it is removed from the patient, to confirm complete excision of the lesion. This allows the surgeon to determine if further tissue removal is necessary during the procedure.The radiologist identifies the suspected lesion on the image and reports the findings to the surgeon.

Example 1: A patient undergoes a lumpectomy for breast cancer. The removed tissue is immediately imaged using 76098 to ensure clear margins. The radiologist informs the surgeon that the margins are clear, and no further tissue removal is necessary., During a skin cancer excision, the surgeon removes a suspicious lesion. Code 76098 is used to examine the specimen. The radiologist detects cancerous cells at the margin of the specimen, prompting the surgeon to remove additional tissue., A patient undergoes a partial nephrectomy for a kidney tumor. The excised tissue is imaged using 76098.The radiologist identifies the tumor within the specimen and confirms clear margins, allowing the surgeon to complete the procedure.

Documentation should include the type of specimen, the reason for the examination, the radiologist's findings (including margin status), and communication of these findings to the surgeon. The operative report should also reference the specimen radiography.

** As of December 1st, 2024, code 76098 is an active CPT code. The information provided is based on the latest available coding guidelines and may be subject to change.