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2025 CPT code 88311

Decalcification procedure; performed separately in addition to the surgical pathology examination code.

Report only one unit of 88311 per specimen.This code is reported in addition to the appropriate primary surgical pathology examination code (88302-88309).

Modifiers may apply depending on the circumstances of service.Consult CPT guidelines and payer specific requirements.

Decalcification is medically necessary when the specimen's calcium content prevents adequate processing and microscopic examination for accurate diagnosis.The necessity is supported by the nature of the specimen and the inability to perform the surgical pathology without prior decalcification.

The lab analyst performs the technical steps of decalcification. The clinician is responsible for obtaining the specimen.

IMPORTANT:This code is an add-on code and must be reported in addition to an appropriate primary code for the surgical pathology examination (88302-88309).It is not reported with Mohs surgery codes.

In simple words: This medical code describes the lab work needed to prepare a bone or other hard tissue sample for examination under a microscope.The lab technician uses special chemicals to dissolve the calcium in the sample, making it easier for the doctor to analyze the tissue for disease.

This CPT code, 88311, represents the decalcification procedure performed on a specimen prior to a surgical pathology examination.The procedure involves treating a calcified specimen (most commonly bone but can include other calcium-containing tissues) with a solution, typically a mineral acid, to dissolve the calcium. This is necessary because the calcium prevents the specimen from being thinly sliced for microscopic examination.The decalcification process is performed by a lab analyst and is reported separately from the surgical pathology examination (codes 88302-88309) which is performed by a pathologist after the decalcification is complete.The unit of service is a single specimen.

Example 1: A patient undergoes a bone biopsy. The biopsy specimen is calcified and requires decalcification before microscopic examination by a pathologist. Code 88311 is reported in addition to the appropriate surgical pathology code., A patient presents with a calcified tumor. Surgical removal of the tumor is performed, and the specimen requires decalcification prior to microscopic analysis. Code 88311 is used alongside the appropriate surgical pathology code., A patient has a bone lesion detected on imaging.A bone core needle biopsy is taken. The core biopsy specimen requires decalcification prior to further microscopic analysis.Code 88311 is reported in addition to appropriate surgical pathology code.

* Documentation of specimen type and source.* Documentation confirming the need for decalcification (e.g., description of specimen hardness).* Pathologist's report detailing the examination performed after decalcification.* Lab report detailing the decalcification method and results.

** The choice of decalcification method (e.g., acid, chelating agent) can affect the preservation of nucleic acids and therefore impact downstream molecular testing if required.Consult with a pathologist to determine the most appropriate method based on the specific specimen and intended analyses.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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