CPT® Code 88309

Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil - resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection

The CPT® Code 88309 refers to a Level VI surgical pathology examination, which involves the gross and microscopic evaluation of tissue specimens removed during various surgical procedures. This examination is critical for diagnosing conditions, particularly malignancies, by providing detailed insights into the cellular and structural characteristics of the tissue. The process begins with the removal of tissue during surgeries 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 identify any notable features or abnormalities. Following this initial assessment, the specimen is prepared for microscopic evaluation, where the pathologist examines the cellular composition in detail. This thorough analysis aids in establishing a definitive diagnosis, determining the presence or absence of cancer, identifying the specific type of malignancy if cancer is present, and assessing the surgical margins to ensure that 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 for further action. The coding for pathology services, including Level VI examinations, is based on various 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 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 V (CPT® Code 88307).