Gross Only

Gross only specimens are part of surgical pathology CPT coding routine in surgical pathology. The CPT manual assigned one code as Level I 88300 Surgical pathology, gross examination only. According to CAP ANP.10016, specimens removed during surgery are ordinary sent to a pathologist for evaluation but there may be policy exceptions. Such a policy is neither mandatory nor requirement for CAP accreditation.

Level I 88300 gross only examination should not be confused with 88329 Pathology consultations during surgery without microscopic examination, namely frozen section. In rare occasions 88329 can be replaced by Level I 88300 (usually this is the case if the clinician sends for intra operative consultation a specimen by mistake). Usually, after 88329 should be either a frozen section/touch prep or a regular microscopic examination , Gross only intraoperative consultation (88329) should not be confused with 88300, but, of course, 88300 cannot be added to 88331 and 88332. Pathology consultation during surgery is discussed in a special section- Intraoperative consultation.

Every institution has a list of specimens for gross examination only. It is created according recommendations professional societies (Appendix L, Professional   Regulations Manual, CAP 2003) and some accreditation authorities (JACHO for instance). Hopefully, this list is periodically updated reflecting the institution’s profile and professional interests of its divisions and individual specialists.  The list is formed by consensus of tissue committee, laboratory director, legal counsel, risk  management, and medical staff (OR/PAR). If the specimen were delivered to the pathology department, the specimen obligatory is exanimate by the pathologist. The difference is only whether it is examined with or without microscopic examination. The Level I 88300 “gross only” is not necessarily presumes any charge in some institutions.

Below is an approximate list of specimens for Level I 88300 gross examinations only with some comments. This list is proprietary for every institution.

Aortic aneurism contents

Aortic plaques

Atrial appendages

Bone fragments to correct orthopedic deformities 9exostosis, bunions, etc.)

Calculi (stones)

Clavicle and acromion fro rotator cuff repair

Foreskin under 1 year age

Meniscus (torn)

Nasal cartilage and bone from plastic surgery or septoplasty from ENT

Lumbar bone and tissue from routine disc surgery

Thymus from congenital heart surgery

Tonsils and adenoids under 18 year age; some institutions practice 14 years cut off age

Placenta (Normal Spontaneous Vaginal Delivery); there is a variety of local policies

Foreign body with attached soft tissue

Tissue from recent traumatic injuries, including amputated extremities

Incomplete list of devices required for tracking under Safe Medical Devices Act of 1990 which require storage in the legal cabinet or transferred to Risk Management office:

a/ permanently implanted devices as

vascular graft prosthesis

vascular bypass (assist) devices

valve replacement material

brain/nerve stimulators

b/ FDA designated devises

electromechanical infusion pumps

inflatable prosthesis

silicon gelfilled prosthesis

List of specimens that do not need to be sent to pathology and be disposed as biomedical waste is determined by institution’s tissue committee according to updated recommendations of College of American Pathologists (Appendix L, Professional Relations Manual, 2003). If these tissues are delivered as specimens, they are in practice considered as required pathology examination. Although pathology department can clarify by calling the clinical department, but as common practice they are accessioned. In many institutions this tissues are sent to pathology just to avoid the disposal problems or to be on the safe side just in case the approximate list includes:

Cataract

Normal toenails and finger nails that are incidentally removed

Skin or other normal tissue removed during cosmetic or reconstructive procedure (e.g. blepharoplasty, cleft palate repair, abdominoplasty, rhytidectomy, and syndactyl repair) provided it
is not contiguous with the lesion and the patient does not have a history of malignancy.

All atherosclerotic plagues except coronary atherosclerosis disease

Aortic aneurism contents

Bone donated to the bone bank

Bone segments removed as part of corrective or reconstructive orthopedic procedure (e.g. rotator cuff repair, synostosis repair, spinal fusion)

Hernia sac

Debridement tissue from burn patients

Tissue expander

Sphenous vein segments harvested for coronary bypass surgery

Middle ear ossicles

Teeth where there is no attached tissue

Dental appliances

Rib segments or other tissue removed only for purpose of gaining surgical access, provided the patient doe not have a history of malignancy

Orthopedic appliances, such as screws, plated, etc.

Intrauterine contraceptive devices without attached soft tissue

Medical devices such as catheters, gastrostomy tubes, myrinatomy tube

Radioactive source

Varicose veins (non-thrombosed)

Bullet should not be sent to pathology, but directed to security department without any exception, but in practice this is not a case. Anyway, bullets, knives, and other legal interest items is not subject of CPT coding anyway.

Bullets and other forensic specimens. These items ought not to go to pathology in the first place, but should be directed to the security department without any exception. Pathology cannot contribute anything besides compromising forensic evidence and possible loss of the precious material. Nevertheless, some institutions impose these duties on the pathology department and even require gross examination. Anyway, in this occasion this is Level I 83000 code.

The lists of gross only specimens and specimens that do not require to be sent to pathology are presented for recognizing them during accession and preliminary CPT coding. For many reasons the clinician or the pathologist can over-ride the protocol based on his/her treatment plan and knowledge of the individual patient and decide that the specimen does require microscopic examination that is the cause of changing the initial CPT code.  Two main features are important to make the code as a chargeable entity: a/ the pathologist must provide a report b/ the gross only code can be changed by the pathologist (only) depending on the finding during grossing (e.g. soft tissue attached to the heart valve prosthesis); of course, in this situation new code would be applied, but never additionally to 88300. This situation requires attention of billing manager because initial accession would be 88300.

Disclaimer

These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

 

 

 

 

 

 

 

 

 

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