CPT® Code 88304

Level III - Surgical pathology, gross and microscopic examination

Abortion, induced
Abscess
Aneurysm - arterial/ventricular
Anus, tag
Appendix, other than incidental
Artery, atheromatous plaque
Bartholin's gland cyst
Bone fragment(s), other than pathologic fracture
Bursa/synovial cyst
Carpal tunnel tissue
Cartilage, shavings
Cholesteatoma
Colon, colostomy stoma
Conjunctiva - biopsy/pterygium
Cornea
Diverticulum - esophagus/small intestine
Dupuytren's contracture tissue
Femoral head, other than fracture
Fissure/fistula
Foreskin, other than newborn
Gallbladder
Ganglion cyst
Hematoma
Hemorrhoids
Hydatid of Morgagni
Intervertebral disc
Joint, loose body
Meniscus
Mucocele, salivary
Neuroma - Morton's/traumatic
Pilonidal cyst/sinus
Polyps, inflammatory - nasal/sinusoidal
Skin - cyst/tag/debridement
Soft tissue, debridement
Soft tissue, lipoma
Spermatocele
Tendon/tendon sheath
Testicular appendage
Thrombus or embolus
Tonsil and/or adenoids
Varicocele
Vas deferens, other than sterilization
Vein, varicosity

The CPT® Code 88304 refers to a Level III surgical pathology examination, which involves both gross and microscopic evaluation of tissue specimens removed during surgical procedures. This examination is critical for diagnosing various conditions, as it allows pathologists to assess the characteristics of the tissue visually before preparing it for microscopic analysis. The process begins with the transportation of the specimen from the surgical suite to the pathology lab, where the pathologist conducts a thorough visual examination to identify any notable features. Following this initial assessment, the specimen undergoes preparation for microscopic evaluation, enabling the pathologist to analyze the cellular structure in detail. This analysis is essential for establishing a diagnosis, determining the presence or absence of malignant neoplasms, identifying the specific type of malignancy if present, and evaluating the margins of the specimen to confirm whether the entire diseased area has been excised. After completing the examination, the pathologist prepares a comprehensive written report of the findings, which is then sent to the treating physician. The coding for pathology services, including Level III examinations, is based on several factors, including the type of tissue examined, the expected condition of the tissue (normal or diseased), the complexity of the examination, and the time required to complete the analysis. For reference, other levels of pathology examinations include Level II (CPT® Code 88302), Level IV (CPT® Code 88305), Level V (CPT® Code 88307), and Level VI (CPT® Code 88309).