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Official Description

Microdissection (ie, sample preparation of microscopically identified target); manual

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

Microdissection is a specialized technique used to isolate and prepare specific cells from a tissue sample for detailed examination. In the context of CPT® Code 88381, this procedure involves the manual separation of microscopically identified target cells. The process is crucial for studying disease at a cellular level, allowing pathologists to analyze the characteristics of abnormal or neoplastic cells in comparison to normal tissue. During the procedure, a thin section of tissue is placed under a dissecting microscope, where the pathologist can visually identify clusters of cells of interest. Using precise instruments such as a razor blade or scalpel, the pathologist manually dissects and extracts these targeted cells. This meticulous approach ensures that the selected cells are preserved for further analysis, which can provide valuable insights into the nature of the disease and inform treatment decisions. The manual technique described in CPT® Code 88381 is essential for cases where laser capture methods are not applicable or when a more hands-on approach is required to obtain the necessary cellular samples.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 88381 is indicated for the following conditions:

  • Targeted Cell Analysis This procedure is performed when there is a need to isolate specific cells from a tissue sample for detailed examination, particularly in cases of suspected neoplasia or other abnormalities.
  • Histopathological Evaluation It is indicated for the evaluation of histopathological features of disease, allowing for the comparison of abnormal cells with normal tissue.
  • Research Purposes The technique may also be utilized in research settings where precise cellular analysis is required to understand disease mechanisms.

2. Procedure

The procedure for CPT® Code 88381 involves several critical steps to ensure the accurate manual dissection of target cells from a tissue sample.

  • Step 1: Preparation of the Tissue Sample The process begins with the preparation of a thin section of the tissue, which is placed on a microscope slide. This section must be thin enough to allow for clear visualization of the cellular structures under the dissecting microscope.
  • Step 2: Microscopic Examination The pathologist then examines the tissue section under a dissecting microscope. This step is crucial as it allows for the identification of specific clusters of cells that are of interest for further analysis, particularly those that appear abnormal or neoplastic.
  • Step 3: Manual Dissection Once the target cells are identified, the pathologist uses a razor blade or scalpel to manually dissect and separate these cells from the surrounding tissue. This requires precision and skill to ensure that only the desired cells are extracted while minimizing damage to adjacent tissues.
  • Step 4: Collection of Target Cells The selected cells are then carefully collected and placed onto a transfer film or another suitable medium for further study. This step is essential for preserving the integrity of the cells for subsequent analysis.

3. Post-Procedure

After the manual dissection procedure is completed, the extracted cells are typically prepared for histological examination or other forms of analysis. The pathologist may document the findings and ensure that the samples are properly labeled and stored for future reference. It is important to monitor the patient for any potential complications related to the tissue sampling, although the procedure is generally well-tolerated. The results obtained from the microdissection can provide critical information that aids in diagnosis and treatment planning, making this procedure a valuable tool in the field of pathology.

Short Descr MICRODISSECTION MANUAL
Medium Descr MICRODISSECTION PREP IDENTIFIED TARGET MANUAL
Long Descr Microdissection (ie, sample preparation of microscopically identified target); manual
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
Type of Service (TOS) 5 - Diagnostic Laboratory
Berenson-Eggers TOS (BETOS) T1G - Lab tests - other (Medicare fee schedule)
MUE 1
CCS Clinical Classification 234 - Pathology
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
GC This service has been performed in part by a resident under the direction of a teaching physician
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
91 Repeat clinical diagnostic laboratory test: in the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. note: this modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. this modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). this modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
GZ Item or service expected to be denied as not reasonable and necessary
90 Reference (outside) laboratory: when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
GA Waiver of liability statement issued as required by payer policy, individual case
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2011-01-01 Changed Short description changed.
2008-01-01 Added First appearance in code book in 2008.
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