Explain how to code surgical pathology reports using CPT.

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CPT (Current Procedural Terminology) coding for surgical pathology reports involves assigning standardized codes to laboratory procedures based on specimen type and complexity. These codes are essential for billing and insurance reimbursement.

1. Understand Surgical Pathology Levels

CPT codes for surgical pathology are divided by level of service (gross and microscopic exam) and specimen complexity, not diagnosis. Codes range from 88300 to 88309.

2. Common CPT Codes

• 88300 – Level I: Gross examination only (e.g., toenail, skin tag).

• 88302 – Level II: Gross & microscopic, minimal complexity (e.g., foreskin in child).

• 88304 – Level III: Low complexity (e.g., appendix, skin).

• 88305 – Level IV: Moderate complexity (e.g., colon biopsy, cervix biopsy).

• 88307 – Level V: High complexity (e.g., larynx, breast mastectomy).

• 88309 – Level VI: Very high complexity (e.g., brain, radical resection specimens).

3. Choose the Right Code

• Identify the specimen type (e.g., colon biopsy).

• Refer to the CPT code descriptions or a coding manual.

• Assign a code based on how complex the gross and microscopic evaluation is.

Example:

• A colon biopsy is coded 88305.

• A colon resection for cancer is 88307 or 88309 based on extent.

4. Special Stains & Additional Services

Use add-on codes for:

• Special stains: 88312–88313

• Immunohistochemistry: 88342

• Frozen sections: 88331–88332

5. Follow Documentation Rules

Ensure:

• Clear documentation of specimen type

• Gross and microscopic findings

• Pathologist's interpretation

Correct CPT coding ensures accurate billing and supports clinical data analysis.

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