Basics of CPT code 88305

Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens. The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in cases where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests.

CPT code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). In addition to CPT coding for prostate needle biopsy, the Centers for Medicare & Medicaid Services (CMS) lists HCPCS code G0416 for gross and microscopic examinations, for prostate needle biopsy, any method.

Bone structure and bone marrow may both be evaluated when medically necessary from a single biopsy. When this occurs only one CPT code may be reported for the procedure, either CPT code 38221 or code 20220. If it is medically necessary to perform separate biopsies, both codes can be reported with the appropriate modifier (59 or XS). However, if a single specimen is submitted for surgical pathology, only one code may be assigned, either CPT code 88305 or 88307.

CPT code 88305 includes different types of biopsies. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. To allow for multiple biopsies for investigation and diagnosis of certain disease entities, Horizon NJ Health shall allow additional maximum unit editing for procedure code 88305 based upon specified diagnoses as provided below:

For the following prostate conditions, up to a maximum of sixteen (16) units of CPT code 88305 shall be considered for reimbursement for the same patient on the same date of service:

• Benign neoplasm of prostate (ICD-10 code D29.1)
• Elevated prostate specific antigen [PSA] (ICD-10 code R97.2-R97.21)
• Enlarged prostate, inflammatory diseases of prostate or other and unspecified disorders of prostate (ICD-10 codes N40-N41.9, N42.0-N42.39)
• Malignant neoplasm of prostate (ICD-10 codes C61, D07.5, D40.0)

For the following gastrointestinal conditions, up to a maximum of eight (8) units of CPT code 88305 shall be considered for reimbursement for the same patient on the same date of service:

• Malignant neoplasm of colon (ICD-10 codes C18-C18.9)
• Malignant neoplasm of rectum, rectosigmoid junction, and anus (ICD-10 codes C19, C20-C21.8)
• Benign neoplasm of colon (ICD-10 codes D12.0-D12.6, K63.5)
• Benign neoplasm of rectum and anal canal (ICD-10 codes D12.7-D12.9,)
• Carcinoma in situ of digestive organs (ICD-10 codes D01.0-D01.3)
• Chronic atrophic gastritis (ICD-10 codes K29.4-K29.41)
• Microscopic colitis (ICD-10 codes K52-K52.9)
• Neoplasm of uncertain behavior of digestive organs (ICD-10 codes D37.3-D37.5, D37.8, D37.9)
• Neoplasms of unspecified nature, digestive system (ICD-10 code D49.0)
• Regional enteritis (ICD-10 codes K50.1-K50.919)
• Ulcerative colitis (ICD-10 codes K51.00, K51.919)
• Unspecified chronic gastritis (ICD-10 codes K29.5-K29.51)

Description of CPT code 88305

Tissue removed during a surgical procedure, such as a biopsy, excision, or resection, is examined macroscopically (gross or visual examination) and then under a microscope. The cells, tissues, or organ are transported from the surgical suite to the pathologist. The pathologist first visually examines the specimen and notes any defining characteristics.

The specimen is then prepared for microscopic evaluation. The physician carefully analyzes the specimen to help establish a diagnosis, identify the presence or absence of malignant neoplasm, identify the exact type of malignancy if present, and examine the margins of the specimen to determine whether or not the entire diseased area was removed. A written report of findings is then prepared and a copy sent to the treating physician.

Pathology services are reported based on the type of tissue examined, whether or not the tissue is expected to be normal or diseased, the difficulty of the pathology exam, and the time required to complete the exam. CPT code 88302 is reported for a Level II pathology examination; CPT code 88304 for a Level III exam; CPT code 88305 for a Level IV exam; CPT code 88307 for a Level V exam; and CPT code 88309 for a Level VI exam.

88305  Level IV – Surgical pathology, gross and microscopic examination

Abortion – spontaneous/missed

Artery, biopsy

Bone marrow, biopsy

Bone exostosis

Brain/meninges, other than for tumor resection

Breast, biopsy, not requiring microscopic evaluation of surgical margins

Breast, reduction mammoplasty

Bronchus, biopsy

Cell block, any source

Cervix, biopsy

Colon, biopsy

Duodenum, biopsy

Endocervix, curettings/biopsy

Endometrium, curettings/biopsy

Esophagus, biopsy

Extremity, amputation, traumatic

Fallopian tube, biopsy

Fallopian tube, ectopic pregnancy

Femoral head, fracture

Fingers/toes, amputation, non-traumatic

Gingiva/oral mucosa, biopsy

Heart valve

Joint, resection

Kidney, biopsy

Larynx, biopsy

Leiomyoma(s), uterine myomectomy – without uterus

Lip, biopsy/wedge resection

Lung, transbronchial biopsy

Lymph node, biopsy

Muscle, biopsy

Nasal mucosa, biopsy

Nasopharynx/oropharynx, biopsy

Nerve, biopsy

Odontogenic/dental cyst

Omentum, biopsy

Ovary with or without tube, non-neoplastic

Ovary, biopsy/wedge resection

Parathyroid gland

Peritoneum, biopsy

Pituitary tumor

Placenta, other than third trimester

Pleura/pericardium – biopsy/tissue

Polyp, cervical/endometrial

Polyp, colorectal

Polyp, stomach/small intestine

Prostate, needle biopsy

Prostate, TUR

Salivary gland, biopsy

Sinus, paranasal biopsy

Skin, other than cyst/tag/debridement/plastic repair

Small intestine, biopsy

Soft tissue, other than tumor/mass/lipoma/debridement

Spleen

Stomach, biopsy

Synovium

Testis, other than tumor/biopsy/castration

Thyroglossal duct/brachial cleft cyst

Tongue, biopsy

Tonsil, biopsy

Trachea, biopsy

Ureter, biopsy

Urethra, biopsy

Urinary bladder, biopsy

Uterus, with or without tubes and ovaries, for prolapse

Vagina, biopsy

Vulva/labia, biopsy

Procedure for code 88305

These examinations would be ordered as a gross and microscopic pathology exam or a gross and microscopic tissue exam. Tissue is submitted in a container labeled with the tissue source, preoperative diagnosis, and patient identification information. Specimens from separate sites must be submitted in separate containers, each labeled with the tissue source. Codes 88304-88309 describe levels of service for specimens requiring additional levels of work due to a presumed presence of disease.

CPT code 88304 describes the lowest level of complexity for diseased or abnormal tissue with each subsequent code (CPT code 88305, 88307, and 88309) describing in ascending order higher levels of complexity and physician work. Specific types of disease and tissue sites are listed for each code in the CPT(r) description.

When to use HCPCS codes G0416 instead of CPT code 88305

Medicare no longer pays 88305 for prostate needle biopsies. G0416 is now the appropriate code for all prostate needle biopsies regardless of the number of biopsies/cores. The new definition of G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) reflects this change.

For commercial payer’s (BCBS, Aetna, Cigna, etc.) you can report the CPT code 88305 x the number of specimen biopsies you have done, but before that you shoud check with payer guidelines.  Some Commercial payer’s will only pay to a certain units of CPT code 88305.

Medicare Fee schedule for CPT code 88305

Below is the cost, price, reimbursement rate for Procedure code 88305 for all the different MAC & locality/region. Also you can check the price or billing of CPT code 88305 with 26 (Professional component) and TC (Technical component) modifier. Billing of Procedure code 88305 with 26 or TC modifier is much less than the global CPT code 88305.

Source link : https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=0&HT=0&CT=3&H1=88305&M=5