`1Definitions for CPT Coding lecture
88331 Frozen sections
Pathological, or intraoperative, consultation provides necessary and precise information
pertaining to diagnosis and prognosis which aid a surgeon in deciding whether to proceed
further or not during surgery.
Services rendered using the codes 88300 through 88309 include accession, examination and
reporting.
o The unit of service for codes 88300 – 88309 is the specimen.
o A specimen is defined as the tissue that is submitted for individual examination
and pathologic diagnosis.
o Two or more specimens representing the different lesions from the same patient
are each appropriately assigned an individual code reflective of its proper level
of services.
Services rendered using the codes 88311 – 88354 and 88399 are not included in the specimen
unit of service and represent additional studies or testing that should be coded in addition to
the specimen code.
— The above codes not include the services designated in codes 88311 – 88365 and
88399 (code in addition if performed)
— CPT 88300 – used for any specimen examining without a microscope.
— CPT 88302 – If a gross and microscopic examination is performed on a specimen
to confirm identification and the absence of disease.
— CPT 88304 – 88309 – Gross, microscopic examination and additional ascending
levels of physician work.
— Any unlisted specimen should be assigned to the code which most closely reflects
the physician work involved.
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If a separate service was performed.
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Which service was it?
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What was the specimen?
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The number of times the service was performed with each specimen.
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Document the stain used and its results.
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Document the specific stains and blocks the stains were performed on.
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If there wasn't any diagnosis on a specific stain, do not use 'normal' or
'noncontributory.' Use “GMS stain negative for H. pylori” or “Iron stores confirmed
by Iron stain.”
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Detail out methods and skills which gave the result.
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Document decalcification for bone specimen. Code 88311 per specimen.
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Document for intra-operative consultations. Gross only exam finding or
microscopic diagnosis (code 88329). If the frozen section (88331), touch prep
(88333) or both (88331/88334).
The unit of service for the gross and microscopic surgical pathology codes (8830088309), pathology consult during surgery (88329, 88331, 88333), EM (88348) and
morphometric analysis (88355-88358) is the specimen!! Separate specimens are usually
submitted in separate containers. It is medically reasonable and necessary to submit the
specimens for individual attention, examination and diagnosis. If a colonoscopy identifies
2 separate polyps at 15 cm and 25 cm, it may be reasonable and necessary to submit
them as separate specimens. If one of the polyps is malignant it is important to future
therapy to know WHICH one is malignant. Multiple biopsies of the same polyp are usually
submitted as a single specimen.
The unit of service for special stains (88312-88319) is EACH stain. If it is medically and
reasonable and necessary to perform the same stain on more than one specimen or more
than one block of tissue from the same specimen, additional units of service (UOS) may
be reported. Provider shall not report more than on unit of service for a stain performed
on a single tissue block. For cytology specimens from a single anatomic site, only one
unit of service shall be reported for each special stain regardless of the number of slides.
One unit of service shall be reported for each special stain regardless of the nu,ber of
smears from an anatomic site. For example, multiple smears of peripheral blood are
Stained with iron stain, only 1 unit of service can be reported. If 3 smears from a bone
marrow aspirate are stained with acid fast stain only one unit of service can be reported
Smears from peripheral blood, 1 iliac crest and a contralateral iliac crest are from 3
separate anatomic sites and three separate anatomic sites and therefore an iron stain
performed on the three CAN be billed 88313 x3.
The unit of service for IHC (88342, 88341, 88344) is each a single or multiplex antibody
stain procedure per specimen. A multiplex ab IHC staining procedure is one that uses
multiple Abs to obtain multiple separately reportable medically reasonable and necessary
results. An antibody stain containing multiple abs that yields a single reportable result is
not a multiplex stain and shall be reported with a single antibody staining code. A IHC
stain with multiple abs that are NOT separately interpretable shall only be reported as
one UOS per specimen. If a single IHC stain for one or more antibodies is performed on
multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or
multiple slides from a hematologic specimen, only one UOS shall be reported for each
separate specimen.
UOS for IF is each antibody staining procedure per specimen.
Cytopathology codes describe different methods of preparation and examination of
different types of specimens,
A cytopathology prep from a fluid, washing or brushing shall be reported using one CPT
code from the CPT code range 88104-88112