CPT® Code 88331

The CPT® Code 88331 refers to a pathology consultation that occurs during a surgical procedure, specifically involving the examination of the first tissue block with frozen sections from a single specimen. In this context, a tissue block is a prepared sample of tissue that has been collected and processed for detailed examination by a pathologist. The primary purpose of this consultation is to assist the surgeon in making immediate decisions regarding the surgical procedure by determining the presence or absence of disease, such as malignancy, and assessing whether the surgical margins are free of disease. This is crucial for ensuring that all affected tissue is removed during surgery, which can significantly impact patient outcomes.

During the procedure, the pathologist conducts a gross examination of the tissue block, which involves visually inspecting the sample for any abnormalities. Following this initial assessment, the tissue block is rapidly frozen to preserve its cellular structure, allowing for thin sections to be cut for microscopic examination. The pathologist then examines these frozen sections under a microscope to provide a detailed analysis of the tissue. This includes reporting on the presence of neoplasms or other diseases, the extent of any involvement, and whether the margins of the tissue are clear of disease. The pathologist communicates initial findings verbally to the surgical team, which can influence immediate surgical decisions. Additionally, a comprehensive written report is generated and included in the patient's medical record for future reference. It is important to note that if a pathology consultation occurs without the examination of a tissue block, CPT® Code 88329 should be reported. For any additional tissue blocks with frozen sections, CPT® Code 88332 is utilized.