2025 CPT code 88388
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Pathology - Surgical Pathology Procedures Pathology and Laboratory Procedures Feed
Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies;used with intraoperative consultation or frozen section.
Modifiers may apply depending on the circumstances of the service. Refer to the official CPT manual for guidance on modifier use.
Medical necessity is established when the non-microscopic analysis is required for appropriate clinical management, such as genetic testing or other advanced molecular studies, that inform the definitive diagnosis and treatment plan. The analysis performed must be clinically indicated. Documentation must support the medical necessity.
The clinical responsibility lies with the pathologist or the laboratory technician performing the macroscopic examination and preparation of the tissue sample for further non-microscopic analysis.The pathologist interprets the results of the analysis, integrating them with the microscopic findings.
In simple words: The lab technician examines a tissue sample without a microscope, prepares a small part of it for testing, and gets it ready for analysis. This might include a quick check during surgery or a frozen sample check.This is an extra charge added to the main procedure cost.
This CPT code, 88388, represents the macroscopic examination, dissection, and preparation of tissue specimens for non-microscopic analytical studies. This procedure is performed in conjunction with a touch imprint, intraoperative consultation (codes 88329-88334), or frozen section.Each tissue preparation (e.g., a single lymph node) requires a separate code.The procedure does not include preparation for microbiologic cultures or flow cytometric studies.It involves the macroscopic (without microscope) examination, dissection of the needed tissue, and preparation for further analysis.
Example 1: A surgeon removes a lymph node during a breast biopsy.The pathologist performs code 88388 to prepare a portion of the node for nucleic acid-based molecular studies, in conjunction with an intraoperative consultation (e.g., 88331)., During a colonoscopy, a polyp is removed. The pathologist uses code 88388 to prepare a section for further genetic testing, in addition to the primary procedure code for the polyp removal., A frozen section is taken during a surgical procedure to quickly assess the nature of a tissue sample. Code 88388 is used to describe the preparation of this section for special non-microscopic analysis before the final microscopic analysis.
Complete documentation should include:* Detailed operative report if performed during a surgical procedure.* Specific identification of the tissue sample.* Description of the preparation methods used.* Indication for the non-microscopic analytical studies.* Report of the non-microscopic analysis results.
** Always refer to the most current CPT manual and payer-specific guidelines for accurate coding and billing practices.This code is an add-on code and requires appropriate primary procedure codes for reimbursement.
- Revenue Code: M5A (SPECIALIST - PATHOLOGY)
- RVU: Information not available in provided text.Refer to CMS guidelines and local payer policies for RVU values.
- Global Days: Not applicable. This is an add-on code.
- Payment Status: Active
- Modifier TC rule: Modifier TC (Technical Component) is not applicable to this code.This is a professional service.
- Fee Schedule: Historical fee schedule data is not available within the provided text.This information is dependent on payer and location.
- Specialties:Pathology, Surgical Pathology, Oncology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center, Hospital Outpatient Department