CPT Code 88305: Surgical Pathology, Gross and Microscopic Examination, Level IV

What is code 88305?

CPT code 88305 is a widely used surgical pathology CPT code that represents the gross and microscopic examination of tissue specimens classified as moderate in complexity or level IV. This service is performed by a pathologist who analyzes the specimen both macroscopically (with the naked eye) and microscopically (under a microscope), in order to detect abnormalities, confirm diagnoses, or rule out disease. These examinations are essential in detecting malignancies, infections, inflammatory conditions, and degenerative changes.

The types of surgical pathology procedures reported under 88305 include the evaluation of specimens from skin excisions, colon or gastric biopsies, breast tissue samples, lymph nodes, gallbladders, and other organs or tissues removed for diagnostic purposes. These specimens require more clinical interpretation and histological assessment than low-complexity samples (e.g., toenails or foreskin) but do not rise to the level of highly complex resections reported under higher-tier codes in the pathology CPT code range (e.g., 88307 or 88309).

88305 plays a central role in the coding process for pathology and laboratory services. Proper selection and use of this code are vital to ensure accurate reimbursement, especially under Medicare and private payer policies. To do so, detailed documentation is required, including the clinical reason for the exam, description of the specimen, and the final diagnosis based on the pathologist’s findings. This information must be captured in the medical record and linked to appropriate ICD-10 codes to establish medical necessity and justify the billed service.

Documentation requirements

To comply with coding guidelines and achieve accurate billing, documentation must be detailed, complete, and reflect the complexity of the pathology service provided. Proper documentation ensures compliance with payer policies and supports medical necessity for the use of CPT 88305.

Required elements include:

• Patient information: Include the patient's full name, medical record number, date of birth, date of service, and the pathologist’s signature to verify identity, establish service dates, and confirm that a qualified provider performed or supervised the examination.
• Specimen details: Document the anatomical source of the specimen (e.g., biopsy site), the number of samples submitted, and whether the tissue was obtained via biopsy, excision, or surgical removal.
• Clinical indication: Provide a clear reason for the pathology review—such as ruling out malignancy, identifying inflammation, or confirming a suspected diagnosis—linked to relevant ICD-10 codes to justify the procedure.
• Gross examination: Record a descriptive macroscopic assessment of the specimen’s size, shape, colour, consistency, and any abnormalities noted during the grossing process.
• Microscopic findings: Include detailed histologic observations, noting cellular structure, presence of pathology (e.g., cancer, dysplasia), and features critical to forming a diagnosis.
• Final diagnosis: Summarize the diagnostic conclusion based on the microscopic findings (e.g., benign lesion, adenoma, carcinoma) to guide treatment and support appropriate code selection.
• Pathologist authentication: Ensure the report is signed and dated by the interpreting pathologist, confirming the accuracy and completeness of the gross and microscopic examination.

Billing guidelines

Billing practices for CPT 88305 must follow payer-specific rules and national coding standards. Accurate coding is key to appropriate reimbursement, and mistakes in specimen categorization or documentation can result in denials or underpayment.

Here are key coding and billing tips:

• Use 88305 for moderate-complexity specimens: This includes a wide range of tissues such as breast biopsies, gastrointestinal tract biopsies, lymph nodes, and excised skin lesions. For example, a benign breast mass excision or colon polyp removal typically qualifies for 88305.
• Avoid miscoding specimen complexity: Do not use 88305 for tissues that fall into lower or higher (e.g., 88307 or 88309) or lower (e.g., 88302 or 88304) complexity categories. Refer to the pathology CPT code list and specimen classification tables provided by the American Medical Association or the Centers for Medicare & Medicaid Services to select the correct CPT codes.
• Avoid bundling errors: Do not bill 88305 with additional pathology services (e.g., special stains or molecular testing) unless supported by documentation and payer policy. Each test must be distinct and medically necessary.
• Pair with appropriate diagnosis codes: The diagnostic code must match the reason for the pathology exam and support medical necessity. For example, use D05.00 (lobular carcinoma in situ) for breast biopsies or K63.5 (polyp of colon) for colon samples.
• Frequency limitations and duplicate billing: Most insurance payers, including Medicare, limit billing of the same code for multiple specimens unless they are from distinctly different anatomical sites and clearly documented. Avoid billing multiple units of 88305 for specimens that could be classified under a single report.
• Utilize a reputable medical billing company: Given the complexity of pathology billing, many practices work with a medical billing company experienced in pathology services to ensure accurate coding, reduce denials, and improve timely reimbursement.

Other relevant CPT codes

• 88302:  Surgical pathology, gross and microscopic examination, level II
• 88304: Surgical pathology, gross and microscopic examination, level III
• 88307: Surgical pathology, gross and microscopic examination, level V