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88305

Surgical Pathology, Gross and Microscopic Examination – Level IV

Code Description

CPT code 88305 is used to report a Level IV surgical pathology examination involving both gross and microscopic evaluation of tissue specimens by a pathologist. It is one of the most commonly reported pathology codes and applies to numerous biopsy and surgical specimens, including skin, colon, stomach, prostate, breast, cervix, and other tissues listed under the CPT descriptor.

When to Use 88305

Common examples include:

  • Colon biopsy evaluation

  • Skin biopsy examination

  • Gastric or intestinal biopsy

  • Breast biopsy pathology

  • Prostate needle biopsy

  • Cervical biopsy

  • Endometrial biopsy

Documentation Requirements

Documentation should include:

  • Medical necessity for the specimen examination

  • Specimen source

  • Gross examination findings

  • Microscopic examination findings

  • Final pathology diagnosis

  • Signed pathology report

Examples
Example 1

A gastroenterologist removes a colon polyp during a colonoscopy and sends the specimen to pathology. The pathologist performs both a gross and microscopic examination and issues a final diagnosis. CPT code 88305 is reported.

Example 2

A dermatologist performs a skin biopsy to evaluate a suspicious pigmented lesion. The tissue specimen undergoes Level IV surgical pathology examination with gross and microscopic analysis, making CPT code 88305 the appropriate code.

Common Billing Mistakes

Common billing mistakes include:

  • Reporting the incorrect surgical pathology level

  • Billing multiple specimens incorrectly

  • Missing documentation identifying the specimen source

  • Billing without a complete pathology report

  • Incorrect use of professional or technical component modifiers (26 or TC)

Related CPT Codes
88302

Surgical Pathology, Level II

88304

Surgical Pathology, Level III

88307

Surgical Pathology, Level V

FAQ

What does CPT code 88305 cover?

CPT code 88305 reports a Level IV surgical pathology service that includes both gross and microscopic examination of eligible tissue specimens.

What specimens commonly use CPT 88305?

Common specimens include colon biopsies, skin biopsies, breast biopsies, prostate biopsies, stomach biopsies, cervical biopsies, and many other tissue samples listed in the CPT descriptor.

Who bills CPT 88305?

The code is typically reported by pathology laboratories or pathologists performing the examination and interpretation of surgical tissue specimens.

When is CPT 88305 commonly performed?

It is commonly performed whenever qualifying biopsy or surgical tissue specimens require gross and microscopic examination to establish a diagnosis.

Procedure Type

Surgical Pathology

Test Type

Complexity

Gross and Microscopic Examination

Level IV