Surgical Pathology Policies

Date Issued: 3/12/2019

Over the past several years, EmblemHealth has been implementing payment policies that reflect guidelines set forth by industry authorities. Our goal is to process claims consistently and in accordance with best practice standards. EmblemHealth has instituted additional payment policies for Surgical Pathology CPT Codes.

 

According to the AMA CPT Manual, “A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. 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.”

 

The new policies will enforce guidelines if the diagnosis does not meet the level of surgical pathology reported.

 

For example, the AMA CPT states that CPT 88302 should be used for the examination of:

 

  • 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