CPT® Code 88307

Level V - Surgical pathology, gross and microscopic examination

Adrenal, resection
Bone - biopsy/curettings
Bone fragment(s), pathologic fracture
Brain, biopsy
Brain/meninges, tumor resection
Breast, excision of lesion, requiring microscopic evaluation of surgical margins
Breast, mastectomy - partial/simple
Cervix, conization
Colon, segmental resection, other than for tumor
Extremity, amputation, non-traumatic
Eye, enucleation
Kidney, partial/total nephrectomy
Larynx, partial/total resection
Liver, biopsy - needle/wedge
Liver, partial resection
Lung, wedge biopsy
Lymph nodes, regional resection
Mediastinum, mass
Myocardium, biopsy
Odontogenic tumor
Ovary with or without tube, neoplastic
Pancreas, biopsy
Placenta, third trimester
Prostate, except radical resection
Salivary gland
Sentinel lymph node
Small intestine, resection, other than for tumor
Soft tissue mass (except lipoma) - biopsy/simple excision
Stomach - subtotal/total resection, other than for tumor
Testis, biopsy
Thymus, tumor
Thyroid, total/lobe
Ureter, resection
Urinary bladder, TUR
Uterus, with or without tubes and ovaries, other than neoplastic/prolapse

The CPT® Code 88307 refers to a Level V 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, particularly in identifying malignancies. The process begins with the removal of tissue through procedures such as biopsies, excisions, or resections. Once the tissue is obtained, it is transported from the surgical suite to a pathologist for analysis. The pathologist first conducts a gross examination, visually inspecting the specimen to note any significant characteristics that may indicate the nature of the tissue. Following this initial assessment, the specimen is prepared for microscopic evaluation, where the pathologist examines the cellular structure in detail. This thorough analysis aids in establishing a definitive diagnosis, determining the presence or absence of cancer, and identifying the specific type of malignancy if cancerous cells are present. Additionally, the examination includes assessing the surgical margins to ensure that the entire diseased area has been excised. After completing the evaluation, the pathologist prepares a detailed written report of the findings, which is then sent to the treating physician. The coding for pathology services, including Level V examinations, is based on various factors such as the type of tissue examined, the expected condition of the tissue, 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 III (CPT® Code 88304), Level IV (CPT® Code 88305), and Level VI (CPT® Code 88309).