Occasionally, pathologists will receive in the lab, a fragile, small piece of tissue that can be macroscopically examined, but the process of fixation and embedding deem the material unviable for microscopic diagnosis. In the event that only a macroscopic exam can be completed, CPT® 88300 (Surgical pathology, gross examination only) can be reported. The additional surgical levels (88302, 88305, 88307 and 88309) would not be appropriate as they require a microscopic examination.
If the specimen comes to the lab with “may not survive processing” or a similar phrase documented:
• An attempt at a microscopic exam in this scenario that yields the expected insufficient tissue for diagnosis result does not change the reportable code – only 88300 is supported because it was known before the tissue was embedded that it likely would not survive.
If the specimen does not come to the lab with a statement about the tissue’s viability documented:
• An attempt at a microscopic exam that yields no diagnosis but documents what is seen – for example “scanty mucosal cells present; insufficient for differential diagnosis” – does support the higher-level surgical charge. A microscopic exam was performed and a result provided, even though it did not lead to a final diagnosis.
One final common scenario in this heading occurs when the specimen comes to the lab with the intention of a gross-only examination but includes a piece of connective tissue:
• The pathologist will need to determine if the tissue warrants its own microscopic evaluation. Adherent tissue without any gross appearance of atypia would simply be bundled with the specimen as incidental, because the tissue is unintended for review. If atypia of some kind is suspected, however, the adherent tissue can be microscopically evaluated and billed accordingly. If a histopathologic abnormality is not confirmed by the microscopic exam, CPT 88302 is most appropriate for the adherent tissue. If modest abnormality is confirmed, the CPT should reflect the type of specimen submitted.
Example: A kidney stone is submitted for gross examination and connective tissue is present. The connective tissue is suspicious for abnormality and submitted for microscopic exam.
• If no abnormality is detected, report 88302
• If abnormality is detected (such as inflammation) report 88305 for kidney biopsy
Hopefully, this provides further clarity on the correct CPT code to assign for these types of specimens.
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