SURGICAL PATHOLOGY CODES
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Services 88300 through 88309 include accession, examination, and reporting. They do not include the services designated in codes 88311 through 88365 and 88399, which are coded in addition when provided

The unit of service for codes 88300 through 88309 is the specimen.

A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Two or more such specimens from the same patient (eg, separately identified endoscopic biopsies, skin lesions, etc.) are each appropriately assigned an individual code reflective of its proper level of service.

Service code 88300 is used for any specimen that in the opinion of the examining pathologist can be accurately diagnosed without microscopic examination. Service code 88302 is used when gross and microscopic examination is performed on a specimen to confirm identification and the absence of disease. Service codes 88304 through 88309 describe all other specimens requiring gross and microscopic examination, and represent additional ascending levels of physician work. Levels 88302 through 88309 are specifically defined by the assigned specimens.

Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code.


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88300 Level I - Surgical pathology, gross examination only


88302 Level II - Surgical pathology, gross and microscopic examination
  • Appendix, Incidental
  • Fallopian Tube, Sterilization Fingers/Toes, Amputation, Traumatic
  • Foreskin, Newborn
  • Hernia Sac, Any Location
  • Hydrocele Sac
  • Nerve
  • Skin, Plastic Repair
  • Sympathetic Ganglion
  • Testis, Castration
  • Vaginal Mucosa, Incidental
  • Vas Deferens, Sterilization
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88304 Level Ill - Surgical pathology, gross and microscopic examination

  • Abortion, Induced
  • Abscess
  • Aneurysm - Arterial/Ventricular
  • Anus, Tag
  • Appendix, Other than Incidental
  • Artery, Atheromatous Plaque
  • Bartholin's Gland Cyst
  • Bone Fragment(s), Other than Pathologic Fracture
  • Bursa/Synovial Cyst
  • Carpal Tunnel Tissue
  • Cartilage, Shavings
  • Cholesteatoma
  • Colon, Colostomy Stoma
  • Conjunctiva - Biopsy/Pterygium
  • Cornea
  • Diverticulum - Esophagus/Small Bowel
  • Dupuytren's Contracture Tissue
  • Femoral Head, Other than Fracture
  • Fissure/Fistula
  • Foreskin, Other than Newborn
  • Gallbladder
  • Ganglion Cyst
  • Hematoma
  • Hemorrhoids
  • Hydatid of Morgagni
  • Intervertebral Disc
  • Joint, Loose Body
  • Meniscus
  • Mucocele, Salivary
  • Neuroma - Morton's/Traumatic
  • Pilonidal Cyst/Sinus
  • Polyps, Inflammatory - Nasal/Sinusoidal
  • Skin - Cyst/Tag/Debridement
  • Soft Tissue, Debridement
  • Soft Tissue, Lipoma
  • Spermatocele
  • Tendon/Tendon Sheath
  • Testicular Appendage
  • Thrombus or Embolus
  • Tonsil and/or Adenoids
  • Varicocele
  • Vas Deferens, Other than Sterilization
  • Vein, Varicosity
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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
  • 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 Bowel
  • 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
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88307 Level V - Surgical pathology, gross and microscopic examination

  • Adrenal, Resection
  • Bone - Biopsy/Curettings
  • Bone Fragment(s), Pathologic Fracture
  • Brain, Biopsy
  • Brain/Meninges, Tumor Resection
  • Breast, Mastectomy - Partial/Simple
  • Cervix, Conization
  • Colon, Segmental Resection, Other than for Tumor
  • Extremity, Amputation, Non-traumatic
  • Eye, Enucleation
  • Kidney, Partial/Total Nephrectomy
  • Larynx, Partial/Total Resection
  • Liver, Biopsy - Needle/Wedge
  • Liver, Partial Resection
  • Lung, Wedge Biopsy
  • Lymph Nodes, Regional Resection
  • Mediastinum, Mass
  • Myocardium, Biopsy
  • Odontogenic Tumor
  • Ovary with or without Tube, Neoplastic
  • Pancreas, Biopsy
  • Placenta, Third Trimester
  • Prostate, Except Radical Resection
  • Salivary Gland
  • Small Intestine, Resection, Other than for Tumor
  • Soft Tissue Mass (except Lipoma) - Biopsy/Simple Excision
  •  Stomach - Subtotal/Total Resection, Other than for Tumor
  • Testis, Biopsy
  • Thymus, Tumor
  • Thyroid, Total/Lobe
  • Ureter, Resection
  • Urinary Bladder, TUR
  • Uterus, with or without Tubes & Ovaries, Other than Neoplastic/Prolapse
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88309 Level VI - Surgical pathology, gross and microscopic examination

  • Bone Resection
  • Breast, Mastectomy - with Regional Lymph Nodes
  • Colon, Segmental Resection for Tumor
  • Colon, Total Resection
  • Esophagus, Partial/Total Resection
  • Extremity, Disarticulation
  • Fetus, with Dissection
  • Larynx, Partial/Total Resection - with Regional
  • Lymph Nodes
  • Lung - Total/Lobe/Segment Resection
  • Pancreas, Total/Subtotal Resection
  • Prostate, Radical Resection
  • Small Intestine, Resection for Tumor
  • Soft Tissue Tumor, Extensive Resection
  • Stomach - Subtotal/Total Resection for Tumor
  • Testis, Tumor
  • Tongue/Tonsil - Resection for Tumor
  • Urinary Bladder, Partial/Total Resection
  • Uterus, with or without Tubes & Ovaries, Neoplastic
  • Vulva, Total/Subtotal Resection
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