When a segment of tissue is taken primarily to extend a surgical margin of resection further into the normal tissue zone, the margin(s) of the new specimen (i.e., the “margins of the margin”) may require microscopic evaluation. This descriptor isn’t listed in CPT®, but the average physician work is comparable to that described by Breast, excision of lesion, requiring microscopic evaluation of surgical margins: code 88307. This is called a complicated surgical margin examination.
A usually fairly small segment of breast tissue taken primarily to extend a surgical margin of resection further into the normal tissue zone can also be an uncomplicated surgical margin (indeed, the majority of surgical margins are uncomplicated). The surgeon may label the specimen “inferior margin” or “lateral margin” or simply “margin,” with only one or two blocks submitted for evaluation, and the report won’t make meaningful mention of the margins of the specimen as the pathologist was not required to microscopically evaluate them with a detailed margin status in the final diagnosis (such as the bolded portions in the examples below). Again, this descriptor isn’t listed in CPT, but the average physician work is comparable to Breast, biopsy, not requiring microscopic evaluation of surgical margins: accordingly, code 88305 is applied to this “uncomplicated” surgical margin.
Example documentation for complicated vs uncomplicated surgical margins:
Example A: Right Breast inferior lateral margin, re-excision
• Gross Description: Inferior and lateral, stitch on the new margin. It consists of a 5.5x2.5x2.0 cm portion of soft adipose tissue, 0.5 cm in thickness between the sutured and opposite un-sutured surface. The suture surface is inked blue and the opposite is inked orange. The specimen is serially sectioned and totally submitted in four cassettes.
• Final Diagnosis: Atrophic breast tissue. Margins negative
• Code 88307, documentation shows the margins of the margin specimen were evaluated
Example B: Breast, Right, medial margin, right breast cavity
• Gross Description: A 2.0 x 1.5 x 0.7 cm fragment of fatty breast tissue oriented at the new margin with a suture. This new margin is inked orange. All processed - 2 cassettes.
• Final Diagnosis: One focus of ductal carcinoma in situ coming to within 2 mm of new margin of excision.
• Code 88307, documentation shows the margins of the margin specimen were evaluated
Example C: Breast, Right, superior margin, right breast cavity
• Gross Description: A 2.5 x 1.5 x 0.7 cm fragment of fatty breast tissue oriented at the new margin with a suture. This new margin is inked red. All processed - 2 cassettes.
• Final Diagnosis: Negative for ductal carcinoma in situ.
• Code 88305, the margins of this margin specimen did not require review
The bold comment in the Final Diagnosis section indicates the margins of the margin specimen were reviewed in specimens A and B. This documentation can sometimes also be found in the synoptic section. Inking or suturing to help orient a breast margin specimen does not by itself determine the CPT.
In either case, the pathologist must exercise good faith judgment specimen-by-specimen to decide which level of charge is the more appropriate - code 88305 or 88307.
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