2025 CPT code 88323
(Active) Effective Date: N/A Pathology and Laboratory Procedures - Surgical Pathology Procedures Feed
Consultation and report on referred material requiring preparation of slides.
Modifiers may be applicable. Modifier 26 is used to indicate the professional component of the service if the technical component was performed elsewhere. Modifier 0839T can be appended when digital scanning is also performed on the slides.
Medical necessity must be established for this consultation. The documentation should clearly demonstrate the reason why the additional consultation and slide preparation are required for accurate diagnosis and treatment planning.This may include uncertainty in the initial diagnosis, complex or rare findings, or the need for specialized expertise.
A qualified provider, typically a pathologist, receives a consultation request and referred material, such as tissue or tissue blocks in paraffin.The pathologist prepares slides with routine or special stains and examines them thoroughly. Finally, a report detailing the evaluation and opinion of the consulting pathologist is created.
In simple words: A pathologist provides a consultation and report on tissue samples sent from another lab, preparing new slides for examination as part of their review.This is often done to get a second opinion or more specialized analysis.
This code represents a consultation and report on referred material that requires the preparation of slides.It involves a pathologist reviewing material (like tissue blocks) from another facility, and preparing additional slides for examination. The preparation of slides is integral to the consultation and is included in the service represented by this code.
Example 1: A patient has a biopsy performed at a small hospital. The tissue sample is sent to a larger medical center for a consultation with a specialist in the specific type of tumor suspected. The specialist prepares and examines new slides and provides a report to the original hospital., A patient has a complex skin lesion removed. The initial pathology report is inconclusive. The slides and tissue are sent to a dermatopathologist for further evaluation.The dermatopathologist requires additional slides to be prepared, specifically deeper sections, for accurate diagnosis. Code 88323 is reported., A patient had surgery to remove a potentially cancerous mass. Slides from the initial pathology review are sent to a specialized cancer center for a second opinion before treatment decisions are made. The consulting pathologist prepares a new set of H&E slides from the original paraffin block and issues their diagnostic report.
Documentation should include the original pathology report, the request for consultation, a description of the material received, the type and number of slides prepared by the consultant, and the consultant’s report detailing the findings and diagnostic interpretation.
- Modifier TC rule: Modifier TC is not applicable. The preparation of slides is an integral part of the procedure.
- Specialties:Pathology subspecialties, such as dermatopathology, neuropathology, or hematopathology. Any specialty requiring pathology consultation.
- Place of Service:Outpatient Hospital, Independent Laboratory, Office