2025 CPT code 88302
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory Procedures - Surgical Pathology Procedures Pathology and Laboratory Feed
Level II surgical pathology; gross and microscopic examination to confirm identification and absence of disease.
Modifier 26 (professional component) may be used if only the professional component of the service is billed. Modifier TC (technical component) may be used if only the technical component is billed. No modifier is used if both components are billed together.
Medical necessity for CPT code 88302 is established when the referring physician orders a pathology examination to confirm the identity of a surgical specimen and rule out disease.The medical necessity is usually determined by the clinical indication for the surgical procedure which yielded the specimen.
The clinical responsibility lies with the pathologist.The pathologist receives the specimen, assigns an accession number, performs the gross and microscopic examination, interprets the findings, and generates a pathology report for the referring physician.
In simple words: The doctor examines a tissue sample to confirm what type of tissue it is and to make sure there's no disease. This includes looking at the sample with and without a microscope and writing a report.
This CPT code encompasses a Level II surgical pathology examination involving both gross and microscopic examination of a specimen.The purpose is to confirm the specimen's identification and the absence of any disease. The procedure includes accessioning (receiving and identifying the specimen), gross examination (visual inspection without a microscope), microscopic examination (using a microscope and stains like hematoxylin and eosin), and reporting of findings.This code is used when a more extensive examination than a gross-only examination (CPT code 88300) is necessary but doesn't require the complexity of higher-level codes (88304-88309).
Example 1: A surgeon removes an appendix during an appendectomy and sends it to the pathology lab. The pathologist uses CPT code 88302 to confirm the tissue is an appendix and that there is no evidence of disease., A patient has a suspicious skin lesion biopsied. The pathologist performs a gross and microscopic examination (CPT code 88302) to confirm the tissue type and the absence of malignancy., During a hernia repair, a portion of the hernia sac is sent for pathology. The pathologist utilizes CPT code 88302 to verify the tissue is hernia sac tissue and to check for malignancy.
* Complete specimen identification and accessioning information.* Detailed description of gross examination findings.* Microscopic examination findings including type and number of stains used.* Diagnostic interpretation and report.
** Code 88302 is used when a gross and microscopic exam is necessary to confirm identification and the absence of disease. This contrasts with code 88300 (gross examination only) and codes 88304-88309 (higher levels of complexity involving additional microscopic examination elements).
- Revenue Code: T1G (LAB TESTS - OTHER)
- RVU: This information is not available in the provided text.Consult the current CPT code book or your payer's fee schedule for RVU values.
- Global Days: Not applicable to this code. Global surgical periods are associated with surgical procedures, not pathology examination codes.
- Payment Status: Active
- Modifier TC rule: Modifier TC is applicable when billing only for the technical component of the pathology service, which would typically be billed by the laboratory.
- Fee Schedule: Fee schedule data is not provided. Check your payer's fee schedule for historical and current payment rates.
- Specialties:Pathology, Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Office