CPT® Code 88302

Level II - Surgical pathology, gross and microscopic examination

Appendix, incidental
Fallopian tube, sterilization
Fingers/toes, amputation, traumatic
Foreskin, newborn
Hernia sac, any location
Hydrocele sac
Nerve Skin, plastic repair
Sympathetic ganglion
Testis, castration
Vaginal mucosa, incidental
Vas deferens, sterilization

The CPT® Code 88302 refers to a Level II surgical pathology service that involves both gross and microscopic examination of tissue specimens. This procedure is essential for the evaluation of various types of tissues that may be removed during surgical interventions, such as biopsies, excisions, or resections. The process begins with the collection of tissue, which is then transported from the surgical suite to a pathologist for analysis. The pathologist conducts a gross examination, visually inspecting the specimen to identify any notable characteristics that may indicate the presence of disease. Following this initial assessment, the specimen is prepared for microscopic evaluation, allowing for a detailed examination of the cellular structure. This step is crucial for establishing a diagnosis, determining the presence or absence of malignant neoplasms, and identifying the specific type of malignancy if one is present. Additionally, the pathologist assesses the margins of the specimen to confirm whether the entire diseased area has been excised. After completing the examination, a comprehensive written report detailing the findings is generated and sent to the treating physician. The coding for pathology services, including 88302, is determined by factors such as the type of tissue examined, the expected condition of the tissue (normal or diseased), the complexity of the examination, and the time required to perform the analysis. For more advanced levels of pathology examinations, other codes such as 88304, 88305, 88307, and 88309 are utilized, each corresponding to different levels of service complexity.