2025 CPT code 88309
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory Procedures - Level VI Surgical Pathology Procedures Feed
Level VI surgical pathology; gross and microscopic examination of complex specimens.
Modifiers may be applicable depending on the specific circumstances of service delivery.Consult current modifier guidelines for appropriate use.
The medical necessity for code 88309 is established by the need for a comprehensive pathological examination of a complex surgical specimen to accurately diagnose and stage a disease, guide treatment, and determine prognosis. The complexity of the specimen, often involving multiple anatomical sites or extensive resection, justifies the Level VI service.
The pathologist is responsible for receiving, accessioning, examining (grossly and microscopically), and reporting on the surgical specimen. This includes proper identification, tissue handling, microscopic analysis (including staining if needed), and generation of a detailed report with a diagnosis and any other relevant information.
In simple words: The doctor examines a surgical sample (like tissue removed during surgery) very carefully, both with and without a microscope. This involves detailed checks and a full report that helps in diagnosis.
This CPT code, 88309, represents a Level VI surgical pathology procedure encompassing gross and microscopic examination of a specimen.The procedure includes accessioning, gross examination (visual inspection without a microscope), microscopic examination (using a microscope and staining techniques), and detailed reporting of findings, including a diagnosis.This level is reserved for the most complex specimens requiring extensive analysis and physician work, such as mastectomies with lymph node dissection, or extensive resections involving multiple anatomical sites.The complexity of the specimen and the extent of the examination dictate the selection of this code.
Example 1: A patient undergoes a radical mastectomy with axillary lymph node dissection for breast cancer. The pathologist receives the surgical specimen and performs a Level VI examination (88309), which involves meticulous gross and microscopic evaluation of the breast tissue and lymph nodes., A patient has a total colectomy for colon cancer.The pathologist receives the entire resected colon and performs a Level VI examination (88309) to assess the tumor's extent, margins, and lymph node involvement., A patient undergoes a partial esophagectomy for esophageal cancer. The pathologist evaluates the resected esophageal tissue with the lymph nodes and other tissues to determine the stage and type of cancer. A Level VI examination (88309) is performed due to the complexity of the specimen and required analysis.
** Code 88309, representing the highest level of surgical pathology service, requires rigorous documentation and careful code selection.Always refer to the most recent CPT codebook and NCCI edits to ensure accurate billing practices.If a specimen’s complexity doesn’t clearly fit into 88300-88309, consider 88399 (unlisted surgical pathology procedure).
- Revenue Code: T1G (LAB TESTS - OTHER)
- RVU: The relative value units (RVUs) for CPT code 88309 vary based on geographic location, payer, and facility type (inpatient vs. outpatient).Consult your specific payer's fee schedule for current RVU values.
- Global Days: Not applicable; this code is for pathology services, not surgical procedures.
- Payment Status: Active
- Modifier TC rule: The Technical Component (TC) modifier does not apply to this professional code.
- Fee Schedule: Historical fee schedule data for CPT code 88309 varies by payer and location. Access historical data from the AMA or specific payer websites.
- Specialties:Pathology, Surgical Oncology, various surgical specialties
- Place of Service:Hospital (Inpatient and Outpatient), Ambulatory Surgical Center, Independent Laboratory