Chapter 18: Pathology and Laboratory

A patient with deep vein thrombosis requires heparin to maintain therapeutic anticoagulation levels. He has regular PTTs drawn to monitor his level of anticoagulation. What code describes this testing? A.85730 B.85520 C.80299 D.None of these

Answer: A. 85730 Rationale: PTT stands for partial thromboplastin time. Look in the CPT® Index for PTT, you are directed to—See Thromboplastin, Partial Time, which directs you to 85730-85732. Checking the listing, 85730 Thromboplastin time, partial (PTT); plasma or whole blood is the correct code for this test.

A test determining the presence or absence of a substance is considered what type of test? A.Qualitative B.Quantitative C.Forensic D.Hematologic

Answer: A. Qualitative Rationale: A qualitative test determines the presence or absence of the substance.

A patient presents with right upper quadrant pain, nausea, and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders an albumin; bilirubin, both total and direct; alkaline phosphatase; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. How should this be coded? A.82040, 82247, 82248, 84075, 84155, 84460, 84450, 82565 B.80076, 82565 C.80076 D.80076-22

Answer: B. 80076, 82565 Rationale: Code the panel when all of the tests listed in the panel are completed. If additional tests are also performed, they are coded separately. The first 7 tests are all listed in code 80076. This leaves creatinine, which is reported with code 82565. Look in the CPT® Index for Panel, this directs you to See Blood Tests; Organ or Disease-Oriented Panel. Look for Blood Tests/Panels/Hepatic Function, and you are directed to 80076. Next, look for Creatinine/Blood directing you to 82565. Verify these codes.

Which term is used with the word pathologist to describe someone specializing in legal or investigational studies? A.In vivo B.Forensic C.Laboratory D.None of the above

Answer: B. Forensic Rationale: The word forensic refers to information related to an investigation of legal matters. A forensic pathologist examines specimens for causes of disease or death related to legal matters.

A patient with rheumatoid arthritis takes nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain. He also has regular blood tests to monitor kidney function due to his long-term use of the NSAIDs. What diagnosis coding describes the need for the test when the results are normal (the patient has no symptoms of liver disease)? A. Z79.1, Z51.81 B. M06.9, Z79.1, Z51.81 C. M06.9 D. Z79.1, M06.9

Answer: B. M06.9, Z79.1, Z51.81 Rationale: Code both the arthritis and the long-term use of NSAIDs. Look in the ICD-10-CM Alphabetic Index for Arthritis/rheumatoid, directing you to M06.9. For the next code, look for Therapy/drug, long term (current) (prophylactic)/ anti-inflammatory directing you to Z79.1. There is an instructional note under category code Z79 to report also any therapeutic drug level monitoring with code Z51.81. This is found in the Alphabetic Index by looking for Monitoring (encounter for)/therapeutic drug level Z51.81. Verify these codes in the Tabular List and read any instructions provided.

A patient has a history of prostate cancer with removal of the prostate and has completed radiation therapy with no recurrence for two years. A PSA is performed to check for any recurrence. The results show a PSA within normal limits. What diagnosis code(s) describe(s) this test? A.C61 B.Z08, Z85.46, Z90.79 C.Z12.5 D.Z00.00

Answer: B. Z08, Z85.46, Z90.79 Rationale: Per ICD-10-CM coding guideline I.C.21.c.8 follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. The follow-up code is sequenced first followed by the history code. Look in the ICD-10-CM Alphabetic Index for Examination/follow-up (routine) (following)/radiotherapy NEC/malignant neoplasm directing you to Z08. Once cancer has been excised and there is no further treatment directed toward the cancer site without recurrence, choose a personal history of malignancy code. Look for History/personal (of)/malignant neoplasm (of)/prostate directing you to Z85.46. Confirm codes in the Tabular List. According to AHA Coding Clinic (2000 Vol. 17 No.4) screening codes are not used for patients who have any sign or symptom of a suspected condition or history of a condition. The instructional note in the Tabular List for Z08 indicates to use additional code to identify any acquired absence of organs (Z90.-). Look in the Alphabetic Index for Absence/prostate (acquired) referring you to Z90.79

A 27-year-old male dies of a gunshot wound. An autopsy is performed to gain evidence for the police investigation and any subsequent trial. What code describes this service? A.88005 B.88025 C.88040 D.88045

Answer: C. 88040 Rationale: Services related to legal investigations and trials are forensic examinations. Look in the CPT® Index for Autopsy/ Forensic Exam, and you are directed to 88040. Read the code to verify this as the correct listing.

A woman has identified a lump in her right breast. After examination, the physician decides a biopsy is indicated. A specimen is sent for pathologic examination. The finding is carcinoma of the breast in the upper inner quadrant. What diagnosis is assigned for the pathologic examination? A. N63.12 B. C80.1 C. C50.211 D. Z01.419

Answer: C. C50.211 Rationale: Always code the most specific diagnosis known. When a diagnosis of carcinoma of the breast has been confirmed, it is inappropriate to code a less specific diagnosis, no matter the reason for the original test. In the ICD-10-CM Alphabetic Index, look for Carcinoma (malignant) (see also Neoplasm, by site, malignant). Go to the Table of Neoplasms, and look for Neoplasm, neoplastic/breast/upper inner quadrant/Malignant Primary (column) C50.2-. Verification in the Tabular List indicates six characters are needed to complete the code. Report C50.211 for the upper inner quadrant of the right breas

The word "pathology" refers to the study of: A.Deterioration B.Direction C.Disease D.Distress

Answer: C. Disease Rationale: The root word path means "disease." The suffix -logy is "study of."

If a patient has a test result indicating a blood alcohol level of .05, what type of test was performed to determine this information? A.Microbiology B.Qualitative C.Quantitative D.Urine dip test

Answer: C. Quantitative Rationale: A quantitative test determines the amount of a substance found in the specimen. A qualitative test determines the presence or absence of the substance.

A patient has been exposed to rabies. He has no signs or symptoms of infection. A test is performed to check for rabies in his blood. What code describes the necessity for the test? A. Z23 B. B97.89 C. Z20.3 D. A82.9

Answer: C. Z20.3 Rationale: The codes in category Z20 are for exposure/contact to a disease without signs or symptoms of infection. Look in the ICD-10-CM Alphabetic Index for Exposure (to)/rabies Z20.3.

What is the code and any required modifier(s) for dipstick urinalysis, non-automated, without microscopy performed in a physician office for a Medicare patient? A.81025-26-QW B.81002-26-QW C.81002-QW D.81002

Answer: D. 81002 Rationale: 81002 is for dipstick urinalysis. Modifier 26 is not needed in the physician office. Code 81002 is a CLIA-waived test, but is one of the codes that does not require modifier QW. Look in the CPT® Index for Urinalysis/Routine.

A patient with Acquired Immune Deficiency Syndrome (AIDS) presents for follow-up care. A total T-cell count is ordered to evaluate progression of the disease. Choose the code(s) for this study. A.86703 B.86360 C.86361, 86359 D.86359

Answer: D. 86359 Rationale: Code 86359 is for total T-cell count. If other studies were performed, they were not ordered and may not be billed, no matter how seemingly appropriate. Look in the CPT® Index for TCells/Count, which directs you to 86359.

Which word describes the study of small life forms? A.Hematology B.Immunology C.In vivo D.Microbiology

Answer: D. Microbiology Rationale: The root words micro (small) and bio (life) combined with the suffix -logy describe the study of small life forms.

A woman comes in for her annual exam with a cervical Pap smear. The results are abnormal, although they are not diagnostic of any specific disease. A second Pap smear is obtained and this test identifies only normal cells. What diagnosis code identifies the medical necessity for the second Pap smear? A.N92.6 B.N92.3 C.N92.4 D.R87.619

Answer: D. R87.619 Rationale: Choose a code that identifies unspecified previous abnormal findings on cervical Pap smear. Although the second test results came back normal, the previous abnormal finding supports the need for a repeat test. Look in the ICD10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/Papanicolaou cervix, directing you to R87.619. Verify this code in the Tabular List.

Abbreviations and Acronyms

BAC - Blood alcohol content (or concentration) Cr - Creatinine CSF - Cerebrospinal fluid Hct - Hematocrit Hgb or Hb - Hemoglobin MRSA - Methicillin-resistant Staphylococcus Aureus PSA - Prostate specific antigen UA - Urine analysis

Key Root Words for Pathology and Laboratory Coding

Bacteri/o - bacteria Bi/o - life Cyt/o - cell Gen/o - gene Hemat/o - blood Immun/o - immune, immune system Micro- small Myc/o - fungus, mold Parasit/o - parasite Path/o - disease Vir/o - virus