2025 CPT code 88304
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory - Surgical Pathology Feed
Level III - Surgical pathology, gross and microscopic examination.
Modifiers may be applicable. Modifier 26 is used for the professional component and modifier TC is used for the technical component.Modifier 59 may be used to indicate a distinct procedural service.
Medical necessity is established by the clinical indication for the surgical procedure that generated the specimen.
The pathologist is responsible for examining the specimen, making a diagnosis, and documenting the findings in a report.
In simple words: A pathologist examines a tissue sample to check for any problems. This includes receiving the sample, looking at it with the naked eye, and then under a microscope. They then create a report of what they find.
This code represents the examination of a surgical pathology specimen by a pathologist, including accessioning, gross examination, and microscopic examination.It applies to specimens such as abscesses, gallbladder, or tendon. The pathologist assigns an accession number, performs gross examination (reviewing observable features without a microscope), and microscopic examination to identify disease or abnormalities, then prepares a detailed report for each specimen, which may include a diagnosis.
Example 1: A patient has a cyst removed. The specimen is sent to pathology for gross and microscopic examination to determine the type of cyst and if it is benign or malignant., A patient has their gallbladder removed. The specimen is examined to confirm the preoperative diagnosis of cholecystitis and to look for other abnormalities., A patient has a tendon biopsy. The specimen is analyzed to assess the cause of tendon pain or inflammation.
The pathology report must include a description of the specimen, the gross and microscopic findings, and a diagnosis. The type of specimen should also be clearly documented.
** For digitization of glass microscope slides for this code, use add-on code +0752T.
- Modifier TC rule: Modifier TC can be used with add-on code +0752T for digitization of glass microscope slides.
- Specialties:Pathology
- Place of Service:Independent Laboratory,Hospital(Inpatient and Outpatient)