2025 CPT code 88300
Effective Date: N/A Pathology and Laboratory Procedures > Surgical Pathology Procedures Feed
Level I - Surgical pathology, gross examination only.
Modifiers may be applicable to code 88300. Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity is determined by the clinical indication for the gross examination, such as confirming the identity of a specimen, identifying gross abnormalities, or triaging for further testing.
The physician receives a surgical pathology specimen and assigns each specimen vial or specimen an accession number. They perform a gross exam, a review of features observed without a microscope, such as color and shape.They then prepare a detailed report for each specimen that may include a diagnosis.
In simple words: A pathologist examines a tissue sample without a microscope to identify it and check for any visible abnormalities. This basic examination includes receiving the sample, looking at it, and creating a report.
The physician, typically a pathologist, performs a level I examination of a surgical pathology specimen. The examination includes accessioning the specimen into the lab, formally receiving the specimen, examining gross features of the specimen, and reporting findings.
Example 1: A patient undergoes a biopsy of a skin lesion. The sample is sent to the pathology lab where the pathologist performs a gross examination to identify the tissue and describe its characteristics before further processing., A surgeon removes a small mass during an exploratory surgery.The specimen is sent for gross examination only to determine if it warrants further microscopic analysis based on initial appearance., A patient has a foreign object removed. The object is sent to pathology for gross examination and description/identification to be included in the patient's medical record.
Documentation should include a description of the specimen, the reason for the examination, and the pathologist's findings from the gross examination.
- Revenue Code: T1G - LAB TESTS - OTHER (MEDICARE FEE SCHEDULE)
- Specialties:Pathology
- Place of Service:Independent Laboratory, Office