2025 CPT code 88305
(Active) Effective Date: N/A Revision Date: N/A Surgical Pathology Procedures - Surgical Pathology Pathology and Laboratory Feed
Level IV - Surgical pathology, gross and microscopic examination.This includes biopsies of various sites like bone marrow, esophagus, or muscle. It involves accessioning, gross examination, microscopic examination, and reporting of findings.
Modifiers may be applicable. For example, modifier 26 is used for the professional component and modifier TC for the technical component.
Medical necessity for 88305 is established by the clinical indication for the biopsy. The documentation should clearly link the biopsy to the patient's symptoms and the need for pathological analysis to guide diagnosis and treatment.
The pathologist is responsible for accessioning the specimen, performing both gross and microscopic examinations, and generating a pathology report that may include a diagnosis. They must ensure proper handling, examination, and documentation of the specimen.
In simple words: The pathologist examines a tissue sample by viewing it with the naked eye and under a microscope to check for any problems. This process includes receiving the sample, examining it, and creating a report.
Level IV - Surgical pathology, gross and microscopic examination: This code encompasses the examination of specimens such as biopsies from bone marrow, esophagus, muscle, and other sites. The procedure involves assigning a unique accession number to each specimen, performing a gross examination to assess visual characteristics like color and shape, conducting a microscopic examination to identify disease or abnormalities, and preparing a detailed report, which may include a diagnosis, for each specimen.
Example 1: A patient undergoes a bone marrow biopsy. The sample is sent to the pathology lab, where it is accessioned, examined grossly and microscopically, and a report is generated to aid in diagnosing a potential blood disorder., A patient has a muscle biopsy performed to investigate muscle weakness. The specimen is processed according to code 88305 to determine the underlying cause of the weakness., A biopsy is taken from the esophagus of a patient experiencing difficulty swallowing. The specimen undergoes gross and microscopic examination to rule out or diagnose conditions such as inflammation or cancer.
Documentation must include a detailed description of the specimen(s), the type of biopsy performed, the gross and microscopic findings, and the resulting diagnosis. Any special stains or additional procedures performed should also be documented.
** Ensure accurate coding by precisely identifying the specimen and its source. Be mindful of NCCI edits and other coding guidelines when billing multiple procedures on the same specimen.
- Revenue Code: T1G - LAB TESTS - OTHER (MEDICARE FEE SCHEDULE)
- Payment Status: Active
- Modifier TC rule: Modifier TC can be used when billing for only the technical component of the service.
- Specialties:Pathology
- Place of Service:Independent Laboratory, Office