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2025 CPT code 88329

Pathology consultation during surgery.

The CPT guidelines specify that codes 88329-88334 represent pathology consultation during surgery. The choice of code depends on the complexity of the consultation and examination performed.

Medical necessity is established when the intraoperative consultation is essential for determining the next steps in a surgical procedure.The consultation must be integral to surgical decision-making, impacting the course or extent of the surgery.

The pathologist provides intraoperative consultation to give immediate information to the surgeon. They may examine tissues removed during surgery to help the surgeon decide how to proceed.

In simple words: While you're in surgery, the doctor might ask another doctor who specializes in examining tissues (a pathologist) to look at a sample of tissue removed during the operation. This helps the surgeon decide what to do next during the surgery.

This code represents a pathology consultation during surgery, where the pathologist provides intraoperative consultation to give immediate information to the surgeon. This often involves evaluating a specimen by gross or microscopic examination to help determine the next steps in the surgical procedure.

Example 1: A patient undergoes surgery for suspected breast cancer. The surgeon removes a lesion and asks for an intraoperative consultation with a pathologist. The pathologist examines the tissue to determine if the margins are clear and if more tissue needs to be removed., During a surgery to remove a brain tumor, the surgeon consults with a pathologist to confirm the type of tumor based on a frozen section analysis. This information helps the surgeon determine the extent of resection necessary., In a colon resection surgery, the surgeon removes a portion of the colon with a suspected cancerous polyp. An intraoperative consultation with a pathologist confirms the presence of cancerous cells in the polyp and helps the surgeon decide whether further resection or lymph node removal is required.

Documentation should include a detailed operative report describing the reason for the consultation, the specific questions asked of the pathologist, the pathologist's findings, and how these findings influenced the surgical procedure. The pathologist’s report should include a description of the specimen received, the methods used for examination (gross and/or microscopic), and the diagnosis rendered.

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