Summary & Overview

CPT 88387: Gross Examination and Specimen Dissection for Nonmicroscopic Analysis

CPT code 88387 represents a pathology gross examination in which an analyst inspects a tissue specimen with the unaided eye, dissects the portion needed for testing, and prepares the tissue for nonmicroscopic analysis. This technical-only procedure is a routine component of surgical pathology workflow and is billed when macroscopic examination and specimen preparation are required without accompanying microscopic interpretation. Nationally, accurate use of 88387 matters because it affects hospital and laboratory billing, resource allocation in pathology departments, and consistency of claims for tissue processing services.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides an overview of billing benchmarks, common payer coverage considerations, and the clinical context that supports appropriate reporting of gross specimen examination services. Readers will find concise explanations of when 88387 is applicable, typical sites of service, and how this service fits into the broader surgical pathology workflow. Data not available in the input will be identified as such in relevant sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare88387CPTpathologygross-examinationspecimen-dissectionlaboratorysurgical-pathologytechnical-componentnonmicroscopic

Billing Code Overview

CPT code 88387 describes a pathology service in which the analyst performs all technical steps using unaided visual inspection to examine a tissue specimen, dissects out the portion required for testing, and prepares the tissue for nonmicroscopic analysis. This procedure encompasses gross examination and specimen dissection without microscopic evaluation.

Service type: Pathology gross examination and specimen dissection for nonmicroscopic analysis
Typical site of service: Hospital laboratory, independent pathology laboratory, or outpatient surgical center laboratory

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient undergoes an outpatient surgical excision of a superficial skin lesion. The specimen is delivered to the pathology laboratory where a histology technician or pathology assistant examines the gross tissue with unaided vision, dissects the portion of interest (such as the lesion or margin), and prepares the tissue for nonmicroscopic testing or ancillary handling (for example, removal of tissue for microbiology culture, special staining, flow cytometry sample allocation, or tissue banking). The workflow includes accessioning the specimen, documenting gross measurements and appearance, photographing if required, describing the portion submitted for downstream tests, placing tissue in appropriate cassettes or containers, and preparing specimens for transport or further processing. This procedure is typically performed in hospital outpatient pathology labs, freestanding pathology laboratories, ambulatory surgical centers, and larger clinics with on-site pathology services. The patient scenario commonly involves benign or suspicious lesions, small surgical excisions, or biopsies where gross dissection and preparation are needed but microscopic examination and interpretation are billed separately.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when only the professional interpretation component of a separate pathology service is billed by a physician.
`TC`	Technical component	Use when billing only the technical work (laboratory processing) performed by the facility or laboratory.
`59`	Distinct procedural service	Use when another procedure performed at the same encounter is distinct and separately reportable from the gross dissection.
`62`	Two surgeons	Use when two surgeons each perform portions of a procedure that result in specimens requiring separate gross preparation and documentation.
`78`	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period	Use when further specimen handling is required after an unplanned return to the OR that affects gross preparation.
`80`	Assistant surgeon	Use when an assistant surgeon contributes to the operative procedure producing the specimen and separate documentation of handling is required.
`22`	Increased procedural services	Use when the gross dissection requires substantially greater work or complexity than typical (document justification).
`52`	Reduced services	Use when the technical aspects of gross dissection are partially reduced or not fully performed.
`53`	Discontinued procedure	Use when the preparation process is begun but discontinued for clinical reasons prior to completion.
`90`	Reference (outside) laboratory	Use when the technical component or preparation is performed by an outside reference laboratory.
`59`	Distinct procedural service	Use to indicate a distinct service when multiple pathology procedures are reported on the same day.
`XU`	Unusual non-overlapping service (X modifier to identify distinct service)	Use when the service is distinct and performed on a separate anatomical site or unrelated tissue specimen.
`QX`	Locum tenens - physician service	Use when a locum tenens physician provides the professional component associated with pathology services.
`QY`	Attending provider requires supervision by a teaching physician	Use when teaching physician supervision rules apply to the professional component.

Taxonomy Code	Specialty	Notes
207P00000X	Anatomic Pathology	Pathologists performing gross examination and oversight.
207K00000X	Clinical Pathology	Laboratory directors and clinical pathologists involved in specimen processing.
390200000X	Pathology Assistants	Pathology assistants who often perform gross dissection and specimen preparation under pathologist supervision.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`88305`	Level IV surgical pathology, gross and microscopic examination, routine examination	Microscopic examination and professional interpretation that commonly follow the gross dissection and preparation performed under `88387`.
`88342`	Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain	Ancillary testing frequently requested on tissue prepared during the gross dissection; tissue allocation and preparation are performed during `88387`.
`88185`	Cytopathology, fine needle aspirate; immediate cytohistologic evaluation	Rapid on-site evaluation may require gross handling and triage of specimens that complement the nonmicroscopic preparation in `88387`.
`99000`	Handling and/or conveyance of specimen for transfer (when used)	Administrative/transport handling sometimes accompanies preparation for outside testing after `88387`.
`88311`	Decalcification, routine, when performed	If bone or calcified tissue is grossly submitted, decalcification is a subsequent technical process linked to the initial dissection and preparation.