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Level IV Surgical Pathology


Synonyms: Biopsy, Gross and Microscopic Pathology, Microscopic Section, Pathologic Examination, Pathology, Skin Lesion(s) Tissue Examination, Surgical Pathology, Tissue Pathology

Gross and microscopic examination
Specimen Required

Tissue specimen in 10% buffered neutral formalin solution or prepared slide or fresh tissue in container on wet ice.

Gross and microscopic examination:
Artery, biopsy
Bone Marrow, biopsy
Bone Exostosis
Brain/Meninges, other than for tumor resection
Breast Biopsy, not requiring microscopic evaluation of margins
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
Pleura/Pericardium – biopsy/tissue
Polyp, Cervical/Endocervical
Polyp, Colorectal
Polyp, Stomach/Small Intestine
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
Stomach, biopsy
Testis, other than tumor, biopsy, castration
Thyroglossal duct/Branchial Cleft Cyst
Tongue, biopsy
Tonsil, biopsy
Trachea, biopsy
Ureter, biopsy
Urinary Bladder, biopsy
Uterus, with or without Tubes and Ovaries, for prolapse
Vagina, biopsy
Vulva/Labia, biopsy

CPT Code(s)