| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Source Code | Description | Comment | CPT | Blocks | Tasks | Specimen Handling | System | ||||||||||||||||||
2 | ABORTI | Abortion, Induced | Rarely used specimen type - most abortions are spontaneous | 88304 | 3 | OBG | ||||||||||||||||||||
3 | ABORTI S | Abortion, Spontaneous | Majority at MC, All from ER | 88305 | 3 | OBG | ||||||||||||||||||||
4 | ABSCES | Abscess | Any site | 88304 | 1 | GEN | ||||||||||||||||||||
5 | ADENOI | Adenoids | 88304 | 1 per side | If both tonsils in one container, 2 caps | ENT | ||||||||||||||||||||
6 | ADRENA | Adrenal, Resection | 88307 | 5 | GEN | |||||||||||||||||||||
7 | ANEURY | Aneurysm | Any site (not for r/o arteritis or temporal artery bx) | 88304 | 1 | H&E | VASC | |||||||||||||||||||
8 | ANUS I | Anal Tag | 88304 | 1 | GI | |||||||||||||||||||||
9 | APPEND | Appendix, Other than Incidental | Appendicitis, tumor | 88304 | 2 | GEN | ||||||||||||||||||||
10 | APPEND I | Appendix, Incidental | With any surgery other than abdominal pain | 88302 | 1 | GEN | ||||||||||||||||||||
11 | ARTERY | Artery, Biopsy | Temporal artery (r/o arteritis). Not for aneurysm or endarterectomy specimens | 88305 | 1 | H&E, Elastic stain | Do not cut, write "TEMP ARTERY" on side of cassette | VASC | ||||||||||||||||||
12 | ATHERO | Atherosclerotic Plaque | Use for endarterectomy | 88304 | 1 | VASC | ||||||||||||||||||||
13 | AUTOPSY | Autopsy | Used for fetal autopsy | None | PED | |||||||||||||||||||||
14 | BARTHO | Bartholin's gland Cyst | 88304 | 1 | OBG | |||||||||||||||||||||
15 | BIOPSY | Biopsy, Unspecified Site not stepped | 88305 | 1 to 3 | GEN | |||||||||||||||||||||
16 | BIOPSY NO TASKS | Biopsy, No charges or processing tasks | ||||||||||||||||||||||||
17 | BIOPSY RIBBON | Biopsy, Unspecified Site with Ribbon | Used for nearly all small ("IR") needle core biopsy samplings | 88305 | 2 | Ribbons, 1 slide, unstained slides | Conservative tissue processing | GEN | ||||||||||||||||||
18 | BLADDE | Bladder biopsy | 88305 | 1 | steps, 2 slides | GU | ||||||||||||||||||||
19 | BLADDE R | Bladder, TUR | Aggregate resection of bladder tumor | 88307 | 1 to 5 | GU | ||||||||||||||||||||
20 | BLADDE T | Bladder, Partial/Total Resection | Also used for cystoprostatectomy if bladder is primary tumor site | 88309 | 15 | GU | ||||||||||||||||||||
21 | BONE B | Bone, Biopsy/Curettings/Path fracture | Primarily used IR biopsies assessing for tumor | 88307 | 1 | ribbons, 1 slide, immunocal if needed | Conservative tissue processing. If possible, separate bone fragments from soft tissue and only decal one block | ORTHO | ||||||||||||||||||
22 | BONE E | Bone Exostosis | Also use this for osteochondroma | 88305 | 1 | decal | ORTHO | |||||||||||||||||||
23 | BONE F | Bone Fragments, Other than Path Fracture | Primarily for debridment | 88304 | 1 | decal | ORTHO | |||||||||||||||||||
24 | BONE G | Bone, Gross only | Use for bone specimen without micros, except joint resections | 88300 | None | ORTHO | ||||||||||||||||||||
25 | BONE R | Bone, Resection | Use for suspected bone tumors | 88309 | 1 to 5 | decal | If possible, separate bone fragments from soft tissue and only decal caps with bone (it is preferable to have at least one tumor block that has not been decalcified) | ORTHO | ||||||||||||||||||
26 | BRACHI | Brachial Cleft Cyst | Also branchial cleft sinus | 88305 | 1 to 3 | ENT | ||||||||||||||||||||
27 | BRAIN | Brain Biopsy, Tumor Resection | Any brain specimen (biopsy or resection) looking for tumor | 88307 | 1 to 10 | If a very small (< 3 mm) biopsy is received, convert to tan cap and add ".PK CORE" in PTOE) for conservative tissue processing. For larger specimens, green caps (no steps or ribbons) are sufficient. Number of caps depends on volume of tissue - brain specimens are entirely submitted up to 10 caps. | NEURO | |||||||||||||||||||
28 | BRAIN O | Brain, Other than for Tumor | Any biopsy or resection for infection, degenerative diseases or seizures | 88305 | 1 to 10 | If a very small (< 3 mm) biopsy is received, convert to tan cap and add ".PK CORE" in PTOE) for conservative tissue processing. For larger specimens, green caps (no steps or ribbons) are sufficient. Number of caps depends on volume of tissue - brain specimens are entirely submitted up to 10 caps. | NEURO | |||||||||||||||||||
29 | BREAST | Breast, biopsy without margins, reduction | Incisional tumor biopsies, reduction mammoplasty | 88305 | 3 | BR | ||||||||||||||||||||
30 | BREAST C | Breast, Core Biopsy | 88305 | 1 | Steps, 4 slides, recut teaching | BR | ||||||||||||||||||||
31 | BREAST M | Breast, Biopsy with Margins, Mastectomy | Partial or total mastectomy | 88307 | 15 | BR | ||||||||||||||||||||
32 | BREAST N | Breast, Mastectomy with Nodes | Mastectomy with axillary nodes | 88309 | 18 | BR | ||||||||||||||||||||
33 | BRONCH | Bronchus, Biopsy | 88305 | 2 | Ribbons, unstained slides (repeat per cap) | Conservative tissue processing | PULM | |||||||||||||||||||
34 | BURSA | Bursa | 88304 | 1 | ORTHO | |||||||||||||||||||||
35 | CARPAL | Carpal Tunnel Tissue | 88304 | 1 | ORTHO | |||||||||||||||||||||
36 | CARTIL | Cartilage, Shavings | 88304 | 1 | decal (if bony tissue) | If no bone, convert to green cap(s) and no decal | ORTHO | |||||||||||||||||||
37 | CERVIX | Cervix, Biopsy | 88305 | 1 | Steps, 1 slide | OBG | ||||||||||||||||||||
38 | CERVIX C | Cervix, Cone Biopsy | 88307 | 4 | Steps, 2 slides | OBG | ||||||||||||||||||||
39 | CHOLES | Cholesteatoma | 88304 | 1 | ENT | |||||||||||||||||||||
40 | CNS AUTOPSY | Post Mortem Examination of Brain | For cases using "FA" report prefix only | None | NEURO | |||||||||||||||||||||
41 | COLON | Colon, Biopsy | May be labeled as cecum, ascending, hepatic flexure, transverse, splenic flexure, descending colon, or rectum - these are all "colon biopsies". For r/o Hirshsprung's, see below | 88305 | 1 | Steps, 1 slide | GI | |||||||||||||||||||
42 | COLON H | Colon, Hirschprungs | Hirshprung's biopsy handling - If separate fresh specimen is received, accession as separate specimen, transfer to formalin, and accession as "COLON H". Do not change any specimen tasks. | 88305 | 1 | Steps x 3, Choline Transporter (CHT) IHC, Calretinin IHC, unstained x 1, steps x 3 | ||||||||||||||||||||
43 | COLON O | Colon, Partial Resec., Other than Tumor | For partial resection, not for tumor (i.e. diverticulosis, obstruction, bleeding) | 88307 | 10 | GI | ||||||||||||||||||||
44 | COLON R | Colon, Segmental Resection for Tumor | May be used for any colon or rectal tumor resection | 88309 | 15 | GI | ||||||||||||||||||||
45 | COLON T | Colon, total Resection | Primarily resection for IBD/UC | 88309 | 10 | GI | ||||||||||||||||||||
46 | COLOST | Colostomy Stoma | Use for any GI stoma removal | 88304 | 2 | GI | ||||||||||||||||||||
47 | CONJUN | Conjunctiva | 88304 | 1 | OPTH | |||||||||||||||||||||
48 | CORNEA | Cornea | 88304 | 1 | OPTH | |||||||||||||||||||||
49 | DEBRID | Soft Tissue, Debridement | May be used for any debridement | 88304 | 1 | GEN | ||||||||||||||||||||
50 | DIVERTI | Diverticulum | Typically small intestine, NOT for colonic diverticulosis | 88304 | 1 | GEN | ||||||||||||||||||||
51 | DUODEN | Duodenum, biopsy | 88305 | 1 | Steps, 1 slide | GI | ||||||||||||||||||||
52 | DUPUT | Dupuytren's Contracture Tissue | May also be listed as palmar or plantar fibromatosis | 88304 | 1 | ORTHO | ||||||||||||||||||||
53 | EMBOLU | Embolus | 88304 | 1 | VASC | |||||||||||||||||||||
54 | ENDOCE | Endocervix, Curettings/Biopsy | 88305 | 1 | OBG | |||||||||||||||||||||
55 | ENDOME | Endometrium, Curettings/Biopsy | 88305 | 1 | Steps, 2 slides | Do not order steps (submit in green caps) if > 2 blocks required to entirely submit specimen. | OBG | |||||||||||||||||||
56 | ESOPHA | Esophagus, Biopsy | 88305 | 1 | Steps, 1 slide | Grossing staff: Order PAS stain if requisition states to "rule out Candida"; yellow cap if PAS stain ordered | GI | |||||||||||||||||||
57 | ESOPHA R | Esophagus, Resection | 88309 | 15 | GI | |||||||||||||||||||||
58 | EXTREM | Extremeity, Trau.Amputation, with micro | Do not use for gross only amputations | 88305 | 3 | ORTHO | ||||||||||||||||||||
59 | EXTREM D | Extremity, Disarticulation | 88309 | 3 green, 1 white | ORTHO | |||||||||||||||||||||
60 | EXTREM G | Extremity, Amputation, Gross Only | 88300 | 0 | ORTHO | |||||||||||||||||||||
61 | EXTREM O | Extremity, Amputation, Non-traumatic | 88307 | 3 green, 1 white | ORTHO | |||||||||||||||||||||
62 | EYE | Eye, Enucleation | 88307 | Send specimen to FMO for consultation with Dr. Keefe if for primary ocular disease; if removed secondary to regional tumor, may process at MC | OPTH | |||||||||||||||||||||
63 | FALLOP | Fallopian Tube, Sterilization | 88302 | 1 | Write "ON END" on side of cap | OBG | ||||||||||||||||||||
64 | FALLOP B | Fallopian Tube, Biopsy | 88305 | 1 | OBG | |||||||||||||||||||||
65 | FALLOP C | Fallopian Tube, Part of Hyst. or Oophor | Use for separately submitted tubes accompanying either an ovary or uterus | no charge | 3 | OBG | ||||||||||||||||||||
66 | FALLOP E | Fallopain tube, Ectopic Pregnancy | 88305 | 3 | OBG | |||||||||||||||||||||
67 | FEMORA F | Femoral Head, Fracture | 88305 | 1 | Decal | If soft tissue is present at fracture site, submit additional non-decalcified tissue in a green cap (in addition to decalcified tissue) | ORTHO | |||||||||||||||||||
68 | FEMORA G | Femoral Head, Gross Only | for degenerative arthritis | 88300 | 0 | ORTHO | ||||||||||||||||||||
69 | FEMORA O | Femoral Head, Other Than Fracture | Usually for aseptic necrosis | 88304 | 1 | Decal | ORTHO | |||||||||||||||||||
70 | FETUS | Fetus, with Dissection | If gross only, use GROSS, if part of POC, use appropriate ABORTI | 88309 | 5 | For all specimen with identifiable fetal parts, specimen is handled by autopsy resident/pediatric pathologist. Page resident on autopsy service to notify of pending examination | OBG | |||||||||||||||||||
71 | FINGER | Finger, Traum. Amputation, with micros | Primarily used for delayed traumatic amputations | 88302 | 3 | ORTHO | ||||||||||||||||||||
72 | FINGER G | Finger, Traum. Amputation, Gross Only | 88300 | 0 | ORTHO | |||||||||||||||||||||
73 | FINGER O | Finger, Amputation, Non-traumatic | 88305 | 3 | ORTHO | |||||||||||||||||||||
74 | FISSUR | Fissure, fistula | 88304 | 1 | GEN | |||||||||||||||||||||
75 | FORESK | Foreskin, Newborn | 88302 | 1 | GU | |||||||||||||||||||||
76 | FORESK O | Foreskin, Other than Newborn | 88304 | 1 | GU | |||||||||||||||||||||
77 | GALLBL | Gallbladder | 88304 | 2 | GI | |||||||||||||||||||||
78 | GANGLI | Ganglion Cyst | 88304 | 1 | ORTHO | |||||||||||||||||||||
79 | GINGIV | Gingiva, Biopsy | 88305 | 1 | Steps, 1 slide | GI | ||||||||||||||||||||
80 | GROSS | Misc. Gross Only | 88300 | 0 | GEN | |||||||||||||||||||||
81 | HEART | Heart, Explant | 88307 | 4 green, 4 tan | CARDI | |||||||||||||||||||||
82 | HEMATO | Hematoma | Any site | 88304 | 1 | GEN | ||||||||||||||||||||
83 | HEMORR | Hemorrhoids | 88304 | 1 | GEN | |||||||||||||||||||||
84 | HERNIA | Hernia Sac, Any Location | 88302 | 1 | GEN | |||||||||||||||||||||
85 | HYDATI | Hydatid of Morgagni/Paratubal cyst | 88304 | 2 | OBG | |||||||||||||||||||||
86 | HYDROC | Hydrocele sac | 88302 | 1 | GU | |||||||||||||||||||||
87 | ILEUM | Ileum, Biopsy | 88305 | 1 | Steps, 1 slide | GI | ||||||||||||||||||||
88 | INTERV | Intervertebral Disc' | 88304 | 1 | ORTHO | |||||||||||||||||||||
89 | JEJUNU | Jejunum, Biopsy | 88305 | 1 | Steps, 1 slide | GI | ||||||||||||||||||||
90 | JOINT | Joint, Resection with Micros | Use for joints other than osteoarthritis | 88305 | 1 green, 1 white | ORTHO | ||||||||||||||||||||
91 | JOINT G | Joint, Resection, Gross Only | Use for osteoarthritis (femoral head, knee, shoulder) | 88300 | 0 | ORTHO | ||||||||||||||||||||
92 | KIDNEY | Kidney, Biopsy | For medical renal disease (not for tumor) | 88305 | 1p, 1if, em | ss, if, em | REN | |||||||||||||||||||
93 | KIDNEY D | Donor Kidney Biopsy for One Legacy | 1 | |||||||||||||||||||||||
94 | KIDNEY R | Kidney, Partial/Total Nephrectomy | 88307 | 15 | GU | |||||||||||||||||||||
95 | KIDNEY T | Kidney, biopsy post Transplant | 88305 | 1p, 1if, em | ss, if, em | REN | ||||||||||||||||||||
96 | LABIA | Labia, Biopsy | 88305 | 1 | Steps, 1 slide | OBG | ||||||||||||||||||||
97 | LARYNX | Larynx, Biopsy | 88305 | 1 | Ribbons, 1 slide | ENT | ||||||||||||||||||||
98 | LARYNX N | Larynx, Partial/Total Resect. with Nodes | 88309 | 15 | ENT | |||||||||||||||||||||
99 | LARYNX R | Larynx, Resection | 88307 | 12 | ENT | |||||||||||||||||||||
100 | LEIOMY | Leiomyomas, Without Uterus | Procedure is "myomectomy" | 88305 | 1 to 5 | If small, one cap. If large, 5 caps. | OBG |