Pathology/Lab Coding Alert

Question: Should we only and always use 88302 for any specimen in which our pathologist simply confirms identification and absence of disease?

California Subscriber

Answer: It is an oversimplification to say that you should "only and always" report 88302 (Level II - Surgical pathology, gross and microscopic examination…) when the pathologist identifies tissue and confirms absence of disease.

Although CPT^® states, "88302 is used when gross and microscopic examination is performed on a specimen to confirm identification and absence of disease," that’s not the end of the story.

Understand listed specimens: Codes 88302-88309 represent ascending levels of pathologist work for the gross and microscopic exam of tissue specimens. Each code includes a number of "listed specimens," and you should report that code when your pathologist examines a listed specimen.

However, if the pathologist examines a specimen that’s not listed, you should assign the appropriate code that "most closely reflects the physician work involved when compared to other specimens assigned to that code," according to CPT^® instruction.

Based on the 88302 CPT^® instruction mentioned earlier, and the fact that the specimens listed as 88302 typically involve "normal" tissue removed incidentally or for reasons other than disease (such as sterilization or plastic repair), you should also assign 88302 to any unlisted specimen for which the pathologist simply confirms identification and absence of disease.