Laboratory/Pathology

Surgical Pathology Billing Tips

CPT Codes: 88300-88399

Surgical pathology is the study of tissues removed from living patients during surgery to help diagnose a disease and determine a treatment plan. Surgical pathology involves gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and nonsurgeons such as, general internists, medic al subspecialists, dermatologists, and intervention radiologists.

A specimen is a tissue sample that is submitted for separate examination and pathologic diagnosis. Each specimen that is to be evaluated has to be identified separately. Sometime several specimens are obtained during a procedure and sent to pathology in separate containers. Other times they may all be placed in one container. If the specimens are all in one container, that is considered one specimen. If the physician uses ink or suture to label and identify each specimen separately, you may bill separately.

Surgical pathology codes are divided into levels I-VI. Each level contains a different specimen or level of diseased tissue. When a specimen is sent to the pathologist, it is inspected. The first level or level I is performing a gross exam only. That just means the pathologist is looking at it with the naked eye. These codes are listed by the type of sample identified, and each level moves up in severity or complexity. It is important to identify what type of sample you’re looking at, how severe it might be, or how progressive the disease is, so that you can categorize it at the right level. Following the surgical pathology level codes are codes for identifying special stains and testing that also can be done.

Level CPT Code Description Code Detail
I 88300 Surgical pathology, Gross examination only Viewing with manual vision
II 88302 Surgical pathology, Gross and microscopic examination The physician is manually viewing plus also looking at tissue, blood, cells, or other specimens with the microscope (e.g., appendix, incidental / fallopian tube, sterilization / finger/toes, amputation, traumatic / foreskin, newborn).
III 88304 Surgical pathology, Gross and microscopic examination The physician is manually viewing plus also looking at tissue, blood, cells, or other specimens with the microscope (e.g., abortion, induced / abscess / aneurysm – arterial/ventricular / anus, tag / appendix, other than incidental).
IV 88305 Surgical pathology, Gross and microscopic examination The physician is manually viewing plus also looking at tissue, blood, cells, or other specimens with the microscope (e.g., abortion – spontaneous, missed / artery, biopsy / bone marrow, biopsy / bone exostosis / brain/meninges, other than for tumor resection / breast, biopsy, not requiring microscopic evaluation of surgical margins / breast, reduction mammoplasty).
V 88307 Surgical pathology, Gross and microscopic examination The physician is manually viewing plus also looking at tissue, blood, cells, or other specimens with the microscope (e.g., adrenal, resection / bone – biopsy / curetting’s / bone fragments, pathologic fracture / brain, biopsy).
VI 88309 Surgical pathology, Gross and microscopic examination The physician is manually viewing plus also looking at tissue, blood, cells, or other specimens with the microscope (e.g., bone resection / breast, mastectomy – with regional lymph nodes / colon, segmental resection for tumor / esophagus, partial/total resection).


Service codes 88300-88309 include accession, examination, and reporting. They do not include the services designated in codes 88311-88365 and 88399, which are coded in addition when provided. The unit of service for codes 88300-88309 is the specimen. Two or more such specimens from the same patient (e.g., separately identified endoscopic biopsies, skin lesions) are each appropriately assigned an individual code reflective of its proper level of service.

Service code 88302 is used when gross microscopic examination is performed on a specimen to confirm identification and the absence of disease.

Service codes 88304-88309 describe all other specimens requiring gross and microscopic examination, and represent additional ascending levels of physician work. Levels 88302-88309 are specifically defined by the assigned specimens.

Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code.

Use the CPT Code Book to determine the level of surgical pathology in the following examples:

  1. Skin
    • 88302 – Level II
      • Skin, plastic surgery
        • Skin in level II is just from a plastic repair. So what they have received in the pathology lab is some skin tissue that was removed strictly for plastic surgery. Maybe it’s part pf a face lift. The surgeon sent the tissue to make sure that there is nothing to be concerned about – there’s no skin cancer or anything else abnormal growing. The surgeon is making sure that the sample is healthy skin.
    • 88304 – Level III
      • Skin, cyst/tag/debridement
        • The sample might be a cyst that was removed; or a skin tag; or perhaps it’s just skin tissue that has been cut away or debrided from a wound, an ulcer or something else and the sample has been sent to pathology for study.
    • 88305 – Level IV
      • Skin, Other than cyst/tag/debridement/plastic repair
        • Skin under level IV, we find that here skin is describes as “other than cyst/tag/debridement/plastic repair.” So if the skin is sent to pathology and it is not a cyst, tag, debridement, or plastic repair and is from some other source, that specimen is coded using level IV. Perhaps it is a lesion that was on the skin or some other type of specimen. Depending on what type of skin tissue being examined or the severity of the disease of the tissue, the code is going to move up or down in levels.
    • There is no higher level for skin
       
  2. Soft Tissue
    • 88304 – Level III
      • Soft tissue, debridement
        • Soft tissue starts at level III and here it is described as soft tissue, debridement. The specimen is soft tissue debrided from a wound or other location. There is also a listing for soft tissue, lipoma, which is a group of fatty cells.
    • 88305 – Level IV
      • Soft tissue, other than tumor/mass/lipoma/debridement
        • Under level IV we can look for soft tissue and now soft tissue is described as ‘other than tumor/mass/lipoma/debridement/” As long as the soft tissue that was removed is not one of those things listed, you code the specimen at that level.
    • 88307 – Level V
      • Soft tissue mass (except lipoma) – biopsy/simple excision
        • When you move up to the next level, look for soft tissue mass (except lipoma) – biopsy/simple excision.
    • 88309 – Level VI
      • Soft tissue tumor, extensive resection
        • Moving on to level VI, you see soft tissue described as a soft tissue tumor with extensive resection.

Reviewed 9/3/2024