2025 CPT code 88331
(Active) Effective Date: N/A Revision Date: N/A Pathology - Surgical Pathology Procedures Pathology and Laboratory Procedures Feed
Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen.
Modifiers may be applied as clinically appropriate. Consult the CPT codebook and payer guidelines for specific modifier usage.
Medical necessity for a frozen section is established when the intraoperative information from the pathologist's examination is critical to guiding surgical management and impacting the patient's treatment plan.The results must directly influence the surgical decisions and subsequent treatment.
The pathologist's responsibility is to provide timely and accurate interpretation of frozen sections during surgery, guiding the surgeon's intraoperative decisions based on the microscopic examination of the specimen.
In simple words: This code covers the pathologist's quick examination of a tissue sample during surgery. The doctor looks at the sample under a microscope to help the surgeon decide what to do next. This is for the first sample looked at.
This CPT code reports a pathology consultation performed during surgery.The consultation includes the examination of the first tissue block, utilizing frozen section(s) from a single specimen.The pathologist's interpretation of the frozen section provides crucial information to guide the surgeon's intraoperative decisions.This code does not encompass additional tissue blocks or specimens; those require separate coding (e.g., 88332).
Example 1: A surgeon removes a suspicious lesion during a breast lumpectomy. A frozen section is prepared and sent to the pathologist for immediate evaluation to determine the adequacy of the surgical margins and the nature of the lesion. Code 88331 is used., During a colon resection, the surgeon encounters a polyp. A frozen section is examined to confirm the diagnosis.Code 88331 is reported., In a brain surgery, a biopsy specimen is obtained. The pathologist performs a frozen section examination to assist the surgeon in deciding further surgical steps. Code 88331 is used. If additional blocks are processed from the same specimen, 88332 would be additionally billed.
Complete documentation is crucial.The medical record should include:* The operative report detailing the surgical procedure.* The pathology report including gross description and microscopic findings.* The indication for the frozen section.* The results of the frozen section interpretation, clearly linking the findings to the surgical decision-making.* The surgeon’s order for the frozen section.
** Accurate coding requires precise documentation of the services performed.If multiple tissue blocks are examined from a single specimen, code 88332 should be added for each additional block beyond the first.If the frozen section is performed on more than one specimen, each specimen will need to be coded appropriately.
- Revenue Code: T1G (LAB TESTS - OTHER)
- RVU: The relative value units (RVUs) for this code will vary depending on factors such as geographic location, payer, and facility type. Consult the specific payer's fee schedule for accurate RVU and reimbursement information.
- Global Days: Not applicable. This is a consultation code, not a surgical procedure code with a global surgical period.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not applicable to this professional service code.
- Fee Schedule: Historical fee schedules are not provided within the source materials. Fee schedules vary depending on the payer and location.
- Specialties:Pathology, Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Hospital Outpatient Department