2025 CPT code 88332
(Active) Effective Date: N/A Pathology and Laboratory Procedures > Surgical Pathology Procedures Feed
Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure).
Modifiers may be applicable to 88332 to provide additional information about the service. For example, modifier 59 may be used to indicate a distinct procedural service.
Medical necessity for 88332 is established when the additional frozen section analyses are essential for guiding intraoperative decision-making, impacting immediate surgical management like resection margins, extent of lymph node dissection, or other critical aspects of the procedure.
The pathologist is responsible for the gross examination, preparation and interpretation of frozen sections, and communication of findings to the surgeon during the surgical procedure. This typically involves rapid processing, analysis and relaying of diagnostic information impacting real-time surgical management.
In simple words: During surgery, a pathologist may examine tissue samples quickly to help the surgeon decide how to proceed. This code covers the examination of each additional tissue sample beyond the first one during such consultations.
This add-on code describes the examination of each additional tissue block with frozen sections during intraoperative pathology consultation, distinct from the primary frozen section procedure (88331). The service includes professional interpretation of frozen sections and often influences surgical decision-making.
Example 1: During a lumpectomy for breast cancer, the surgeon removes the tumor and sends a tissue sample to the pathologist for frozen section analysis (88331). To assess the margins thoroughly, the surgeon excises additional tissue from the surrounding area and submits a second sample for frozen section evaluation. This second sample is billed as 88332., In a case of suspected melanoma, the surgeon performs a biopsy and sends the tissue for frozen section examination (88331). Due to the irregular shape of the lesion, the surgeon removes two additional tissue samples from different areas of the lesion to check if the cancer has spread. These subsequent samples are billed with two units of 88332., During a partial nephrectomy, a frozen section is performed to evaluate the tumor margin (88331). The surgeon then decides to also biopsy a nearby lymph node and have it examined by frozen section to check for metastasis. The lymph node biopsy examination is reported as 88332.
Documentation should include a detailed operative report describing the surgical procedure, the number and location of tissue samples sent for frozen section, the pathologist's findings, and how these findings influenced the surgical course. The pathology report should also document the gross and microscopic findings from the frozen sections and subsequent permanent sections.
- Specialties:Pathology, General Surgery, Surgical Oncology, and other surgical specialties depending on the specific procedure.
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, and potentially other places of service where intraoperative consultations are performed.