AAPC - Chapter 18 Review Exam, AAPC Chapter 18: Pathology/Laboratory

Z00.5

A 17 year-old female has a bone marrow biopsy for examination as a potential volunteer stem cell donor for her mother who has acute monocytic leukemia (AML). What diagnosis code(s) is/are used for the typing of the stem cell specimens?

Z00.5 Rationale: Only the donor code is used. The bone marrow specimen is being examined to identify a potential donor. The diagnosis of the potential recipient is not coded. In the ICD-10-CM Alphabetic Index look for Donor/potential/examination of you are directed to Z00.5.

A 17 year-old female has a bone marrow biopsy for examination as a potential volunteer stem cell donor for her mother who has acute monocytic leukemia (AML). What diagnosis code(s) is/are used for the typing of the stem cell specimens?

88040

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?

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

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?

82948, 82948-91

A 35 year-old type II diabetic is feeling weak. The physician performs a stat glucose test in which a finger stick is done placing the drop of blood on a reagent strip. The test indicates the patient is hypoglycemic. The physician gives the patient some glucose supplements and performs another stat glucose test using the same lab test as before 30 minutes later. The second test shows the glucose levels returned to normal. How are the lab tests reported?

80162

A cardiac patient must take digoxin to treat his atrial fibrillation (Afib). This condition has been controlled for several years but the patient now presents to his physician with new complaints of irregular heartbeats. The physician orders a total digoxin study to determine the total level of digoxin in order to measure the drug's efficacy in treating his Afib. What CPT® code is reported?

89300, 89329

A couple has been trying to conceive for nine months without success. Preliminary studies show the woman ovulates and the husband's sperm count is good. A sperm sample is submitted for both a post coital Huhner test and a hamster penetration test. Report the codes.

89320, N46.11

A couple with inability to conceive has fertility testing. The semen specimen is tested for volume, count, motility and a differential is calculated. The findings indicate infertility due to oligospermia. What CPT® and ICD-10-CM codes are reported?

R78.0

A lab test reveals an excessive level of alcohol in the blood. What ICD-10-CM code is reported?

R78.0 Rationale: Look in the ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/in blood (of substance not normally found in blood)/alcohol (excessive level) R78.0. Verification in Tabular List confirms R78.0 is for finding of alcohol in blood.

A lab test reveals an excessive level of alcohol in the blood. What ICD-10-CM code is reported?

88305, 88331, 88311, N60.32 Rationale: Code 88305 is for examination of biopsy specimen without margins. Also code the decalcification procedure and frozen section. Use the final diagnosis for all services. In the CPT® Index, look for Pathology and Laboratory/Surgical Pathology/Gross and Micro Exam/Level IV; also look for Consultation/Surgical Pathology/Intraoperative; also see Pathology and Laboratory/Surgical Pathology/Decalcification Procedure directing you to 88311. For the ICD-10-CM code, look in ICD-10-CM Alphabetic Index for Fibrosclerosis/breast directing you to N60.3-. Verification in the Tabular List shows that a 5th character is needed to indicate laterality, report 2 for the left breast.

A left breast biopsy is performed on a mass and the surgeon requests a frozen section examination of the specimen to determine whether more extensive resection is appropriate. The frozen section reveals no indications of malignancy. No other specimen is obtained but the remainder of the biopsy specimen is sent for further testing and examination, including decalcification. The results indicate breast fibrosclerosis only. What CPT® and ICD-10-CM codes are reported?

87177, 81000, B65.0 Rationale: Look in the CPT® Index for Smear and Stain/Ova and Parasites Smear. Code 87177 is correct to report for direct smear. Code the urinalysis with microscopy (81000). In the CPT® Index, look for Urinalysis. The diagnosis code for Schistosomiasis is B65.0. In the ICD-10-CM Alphabetic Index, look for Schistosomiasis/bladder.

A major university medical center has an International Clinic specializing in treating individuals who move to the USA bringing with them diseases and conditions native to their home countries. A Brazilian woman presents to this clinic with complaints of hematuria and fatigue. Urine analysis with microscopy identifies eggs in the urine and further testing from a stool sample identifies Schistosomiasis through direct smear to concentrate and evaluate ova. What CPT® and ICD-10-CM codes are reported?

80400

A patient arrives at to the ED. It appears the patient has been suffering from periods of disorientation, persistent stomachache, fatigue, over the past several months but the persistent patch of dark skin that appeared on the patient's chest has prompted his visit. The treating ED physician orders a stimulation panel for adrenocorticotropic hormone (ACTH) consisting of two cortisol injections, 60 minutes apart. Blood tests reveal ACTH levels are at 300 nmol/L, and diagnoses the patient with adrenal insufficiency. What CPT® codes are reported for the lab services?

88304 x 2

A patient has a cholecystectomy and a soft tissue lipoma removed during the same operative session. Both specimens were sent to pathology in separate containers are examined by the pathologist. What CPT® code(s) are reported?

80502

A patient has a cytopathology study performed by a fine needle aspiration. The results are quite unusual and the slides as well as a copy of pertinent information from the patient's record are sent to another cytopathologist for consultation. The consulting pathologist reviews the slides and reviews the patient's chart material. A report is sent back to the original pathologist with the findings. What CPT® code is reported?

80502 Rationale: Pathology consultation with review of the patient's record is coded 80502. The E/M consultation codes require a face-to-face encounter with the patient. In the CPT® Index, look for Consultation/Clinical Pathology directing you to 80502.

A patient has a cytopathology study performed by a fine needle aspiration. The results are quite unusual and the slides as well as a copy of pertinent information from the patient's record are sent to another cytopathologist for consultation. The consulting pathologist reviews the slides and reviews the patient's chart material. A report is sent back to the original pathologist with the findings. What CPT® code is reported?

88305, 88312, 87181 x 5, K29.40, B96.81, Z16.29

A patient has a history of chronic atrophic gastritis which has been identified as due to Helicobacter pylori. Although previously eradicated with almost complete resolution of gastritis symptoms, the patient has recently begun experiencing pain and other symptoms indicating the infection may have recurred. A biopsy of the stomach was obtained with a gross and microscopic examination performed with an order to verify the presence of H. pylori and, if present, perform sensitivity studies for possible resistant strains. Testing of the biopsy specimen with acid-fast stains confirms chronic gastritis due to H. pylori. Agar dilution studies for susceptibility to five antibiotics are performed. The susceptibility studies indicate resistance to clarithromycin (a macrolide antimicrobial). What codes are reported for the diagnosis and procedure to identify the infectious agent, and test for susceptibility?

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

A patient with deep vein thrombosis requires heparin to maintain therapeutic anticoagulation levels. He has regular PTT's drawn to monitor his level of anticoagulation. What code describes this testing?

M06.9, Z79.1, Z51.81

A patient with rheumatoid arthritis takes Non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain. He also has regular blood tests to verify he has not developed any liver problems due to his use of the NSAIDs. What code(s) describe(s) the need for the test when the results are normal (the patient has no symptoms of liver disease)?

81211 Rationale: In the CPT® Index, look for Breast/Cancer Gene Analysis/BRCA1 (breast cancer 1) referring you to 81162, 81211-81215. The correct code is 81211. This is a blood test performed to look for any gene mutations affecting the BRCA1 and BRCA2 genes. These human genes are known as tumor suppressors, mutation of these genes has been linked to hereditary breast and/or ovarian cancer. A woman's risk of developing breast or ovarian cancer is increased if she inherits this harmful mutation. Men with this mutation also have an increased risk of breast cancer. Be sure to read the parenthetical instructions.

A patient's mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. Blood will be tested for full sequence analysis and common duplication or deletion variants (mutations) in BRCA1, BRCA2 (breast cancer 1 and 2). What CPT® code is reported for this molecular pathology procedure?

81162

A patient's mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. Blood will be tested for full sequence analysis and common duplication or deletion variants (mutations) in BRCA1, BRCA2 (breast cancer 1 and 2). What CPT® code(s) is (are) reported for this molecular pathology procedure?

85379 Rationale: Check for unfamiliar abbreviations in the Index. Read codes closely to identify whether they are quantitative, semi-quantitative or qualitative. In the CPT® Index, look for FDP, you are directed to See Fibrin Degradation Products, this refers you to See Pathology and Laboratory/Fibrin Degradation Products/Quantitative directing you to 85379.

A physician orders a quantitative FDP. What CPT® code is reported?

86900, 86901 Rationale: Patient is getting two different lab tests. The first lab test is to determine if the patient has O, A, B or AB blood type. In the CPT® Index, look for Blood Typing, Serologic/ABO only, you are directed to code 86900. The second lab test is to determine if the patient is negative or positive for the Rh antigen. For the Rh factor, look in the CPT® Index, for Blood Typing, Serologic/Rh (D), you are directed to 86901.

A pregnant patient is tested for serologic blood type and Rh factor. What CPT® code(s) are reported?

RATIONALE: A qualitative test determines the presence or absence of the substance.

A test determining the presence or absence of a substance is considered what type of test? Qualitative

81025

A urine pregnancy test is performed by the office staff using the Hybritech ICON (qualitative visual color comparison test). What CPT® code is reported?

Presumptive Rationale: Presumptive identification identifies microorganisms like viruses by observing growth patterns and other characteristics.

A virus is identified by observing growth patterns on cultured media. What is this type of identification is called?

R87.619

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?

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 ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/Papanicolaou cervix directing you to R87.619. Verify this code in the Tabular List.

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?

C50.211

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?

Z20.3 Rationale: When there is known exposure without symptoms, use the Z code for exposure to communicable diseases. In the ICD-10-CM Alphabetic Index, look for Exposure (to)/rabies. You are directed to Z20.3.

A young man is bitten by a dog found to have rabies. Although he shows no symptoms of rabies, testing is done to see if he has the infection. The tests come back negative. What diagnosis code is used to establish the medical necessity for the service?

87641 A49.02

CASE 1 R/O MRSA - Central line catheter Clinical Indications:(Clinical indications provide medical necessity when there are no other findings.) Patient with fever not responsive to antibiotics Collected: 03/30/XX 17:45 Accession Num: TXXXXX Status: Authenticated Method: Single nucleic acid sequence (Note the method used to identify the infectious agent and/or resistance.) Culture: Methicillin Resistant Staphylococcus aureus (MRSA) isolated (Select the diagnosis code based on the findings.) What are the CPT® and ICD-10-CM codes?

P Rationale: In the HCPCS codebook, P2028-P9615 report Pathology and Laboratory Services including chemistry, toxicology and microbiology tests, screening Pap procedures and various blood products.

HCPCS Level II codes specifically for Pathology and Laboratory services all start with what letter?

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.

If a patient has a test result indicating a blood alcohol level of .05, what type of test was performed to determine this information?

Bethesda

If the findings on examination of a Pap smear are normal and described as "negative for intraepithelial lesion or malignancy" this is an example of what type of results reporting?

86910 x 2-32, Z02.81 Rationale: Always choose codes identifying the service and reason for the service as specifically as possible. Parenthetic comments in CPT® can sometimes assist in finding a challenging code. Modifier 32 is appropriate when services are mandated by courts or insurers. In the CPT® Index, look for Paternity Testing 86910, 86911. One unit of 86910 represents testing for one person. The test is reported with two units because the plaintiff and child were tested. In the ICD-10-CM Alphabetic Index, look for Encounter (with health service) (for)/administrative purpose only/examination for/paternity testing directing you to Z02.81.

In a legal hearing to determine child support there is a dispute about the child's paternity. The court orders a paternity test, and a nasal smear is taken from the plaintiff and the child. The plaintiff is confirmed as the father of the child. Choose the CPT®, ICD-10-CM codes and modifier for the paternity testing.

80050

Mr. Bowen is having a pre-employment physical (screening). His doctor ordered the following serum blood tests: CBC, automated, automated differential WBC, comprehensive metabolic panel and a thyroid stimulating hormone (TSH) assay. Code the services for these labs.

Cortisol x 2, 17 Hydroxyprogesterone x 2

Referring to the CPT® codebook in the Evocative/Suppression subsection, if a patient has congenital adrenal hypoplasia (CAH) and testing is performed to identify if the insufficiency is due to 21 hydroxylase deficiency (insufficient stimulating hormones or inability to react to those hormones), what substances are tested for and how many times must the tests be performed?

Quantitative

Tests in the Chemistry section of CPT® are what types of tests unless specified otherwise?

Other Procedures

The code for sweat collection by iontophoresis can be found in what section of the Pathology Chapter of CPT®?

Study of Rationale: -ology means the study of.

The suffix -ology means

Disease RATIONALE: The root word path means "disease". The suffix ~logy is "study of".

The word "pathology" refers to the study of:

Z85.3

What ICD-10-CM code is reported for a personal history of malignant neoplasm of the breast?

Z85.3 Rationale: Look in ICD-10-CM Alphabetic Index for History/personal/malignant neoplasm (of)/breast Z85.3. Verification in the Tabular List confirms Z85.3 is for personal history of malignant neoplasm of breast.

What ICD-10-CM code is reported for a personal history of malignant neoplasm of the breast?

R87.619

What ICD-10-CM code is reported for an abnormal cervical pap smear?

R73.9 Rationale: Look in the ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/blood sugar/high R73.9. The code can also be found by looking for Elevated, elevation/blood sugar R73.9. Verification in Tabular List confirms R73.9 is for Hyperglycemia, unspecified.

What ICD-10-CM code is reported for elevated blood sugar?

C78.01, C78.02, C80.1

What diagnosis codes are reported for metastatic adenocarcinoma to the lungs from an unknown primary location?

Services related to in vitro fertilization Rationale: These codes describe services related to in vitro fertilization.

What do the services in the Reproductive Medicine Procedures section of the Pathology and Laboratory chapter of CPT® report?

in the living body

What does "in vivo" mean?

in the living body Rationale: In vivo means "in the living body" and is used to describe studies to analyze blood components, percutaneously obtained, in the body.

What does "in vivo" mean?

81003-QW

What is the code and any required modifier(s) for dipstick urinalysis, automated, without microscopy performed in a physician office for a Medicare patient?

81002

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?

81002 RATIONALE: 81002 is for dipstick urinalysis. Modifier 26 is not needed in the physician office and QW is not required. Look in the CPT® Index for Urinalysis/Routine.

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?

88307

What is the code for gross and microscopic examination (surgical pathology) of breast tissue from a simple mastectomy?

88307 Rationale: In the CPT® Index, look for Pathology and Laboratory/Surgical Pathology/Gross and Micro Exam. Review these codes to determine the correct code. There are a number of codes for examination of breast tissue. The coder must be careful to choose the code describing the exact specimen received. Simple mastectomy is listed under 88307.

What is the code for gross and microscopic examination (surgical pathology) of breast tissue from a simple mastectomy?

Antibody

What is usually found in the blood if a person has or used to have an infecting virus?

Antibody Rationale: Antibodies remain in the blood long after the antigen (the substance that causes antibodies to form) may be gone.

What is usually found in the blood if a person has or used to have an infecting virus?

86927 x 4

What is/are the code(s) for thawing 4 units of fresh frozen plasma?

86927 x 4 Rationale: In the CPT® Index, look for Plasma/Frozen Preparation and you are directed to 86927. Code 86927 is specifically for plasma rather than whole blood. The code is used per unit with 86927 x 4 as correct.

What is/are the code(s) for thawing 4 units of fresh frozen plasma?

26

What modifier identifies the professional component of a service?

QW

What modifier must always be applied to Medicare claims for tests performed in a site with a CLIA Waived certificate?

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.

Which term is used with the word pathologist to describe someone specializing in legal or investigational studies?

Microbiology RATIONALE: The root words micro (small) and bio (life) combined with ~logy describe the study of small life forms.

Which word describes the study of small life forms?

88182 Rationale: Flow cytometry is a cytopathologic study. Code 88182 specifies flow cytometry for DNA analysis. Look in the CPT® Index for Flow Cytometry.

Flow cytometry is performed for DNA analysis. What CPT® code is reported?

86359 Rationale: Code 86359 is for total T-cell count. If other studies were performed and they were not ordered they may not be billed, no matter how seemingly appropriate. In the CPT® Index, look for T Cells/Count.

A patient with AIDS presents for follow up care. The total T-cell count is ordered to evaluate any progression of the disease. What CPT® code(s) is/are reported

88305, 88312, 87181 x 5, K29.40, B96.81, Z16.29 Rationale: Code separately for examination of the biopsy specimen, use of acid-fast stain, and each of the 5 agar dilution tests performed. In the CPT® Index, look for Pathology and Laboratory/Surgical Pathology/Gross and Micro Exam/Level IV directing you to 88305 and then look further down and find Special Stain directing you to 88312. In the CPT® Index, also look for Antibiotic Sensitivity/Susceptibility Studies. ICD-10-CM codes should include the gastritis, infectious organism and the Z code identifying the substance the organism is resistant to. In the ICD-10-CM Alphabetic Index, look for Gastritis/chronic/atrophic directing to K29.40. Next look for, Infection/Helicobacter pylori/as the causes of disease classified elsewhere directing to B96.81. Then look for Resistance, resistant (to)/ organism(s)/to drug/macrolides directing you to Z16.29. Verify all codes in the Tabular List.

A patient has a history of chronic atrophic gastritis which has been identified as due to Helicobacter pylori. Although previously eradicated with almost complete resolution of gastritis symptoms, the patient has recently begun experiencing pain and other symptoms indicating the infection may have recurred. A biopsy of the stomach was obtained with a gross and microscopic examination performed with an order to verify the presence of H. pylori and, if present, perform sensitivity studies for possible resistant strains. Testing of the biopsy specimen with acid-fast stains confirms chronic gastritis due to H. pylori. Agar dilution studies for susceptibility to five antibiotics are performed. The susceptibility studies indicate resistance to clarithromycin (a macrolide antimicrobial). What codes are reported for the diagnosis and procedure to identify the infectious agent, and test for susceptibility?

Z08, Z85.46 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, code 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.

A patient has a history of prostate cancer with removal of the prostate and has completed radiation therapy with no recurrence for 2 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?

88300

A patient has a severe traumatic fracture of the humerus. During the open reduction procedure, the surgeon removes several small pieces of bone embedded in the nearby tissue. They are sent to Pathology for examination without microscopic sections. The pathologist finds no evidence of disease. How should the pathologist code for his services?

R83.6

A patient has a traumatic head injury and some cerebrospinal fluid (CSF) is removed to limit potential damage from swelling of the brain. The CSF is sent to pathology for examination and the results show unusual cytological counts, although no specific findings. The patient has had no previous symptoms known to his family members. What is the ICD-10-CM code for this examination of CSF?

Z20.3

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?

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.

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?

88309, 88305, 88313, 88331

A patient has partial removal of his lung which is sent in for gross and microscopic examination. The pathologist also did gross and microscopic exam on biopsies for several lymph nodes in the patient's chest which are placed in one container. A consultation is performed on a tissue block of a single specimen intraoperatively by frozen section. The pathologist also performs a trichrome stain. What CPT® codes are reported for the lab tests performed?

80076, 82565

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?

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 you are directed to 80076. Next, look for Creatinine/Blood directing you to 82565. Verify these codes.

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?

Screening services

A patient presents with worries she is at risk for cancer. She asks for tests to verify whether she has cancer. The test comes back normal. What type of service is this considered?

86817, 86821

A patient will be undergoing a transplant and needs HLA tissue typing with DR/DQ multiple antigen and lymphocyte mixed culture. How will these services be coded?

86357 Rationale: Although there are a number of cells that attack viruses and other infectious organisms, NK cells are specifically identified by code 86357. In the CPT® Index, see Natural Killer (NK) Cells count.

A patient with AIDS presents for follow up care. An NK (natural killer cell) total count is ordered. What CPT® code(s) is/are reported?

80430, 82947

A patient with abnormal growth had a suppression study that included 4 glucose tests and 4 human growth hormone tests. What CPT® code(s) is/are reported?

88307, 88311; L97.511

CASE 10 Requested by D Smith, MD. The pathologist providing the service is an employee of the lab. SURGICAL PATHOLOGY REPORT CLINICAL DATA: Chronic infected skin ulcer status post amputation of first and third toes, current mid transmetatarsal amputation. GROSS AND MICROSCOPIC DESCRIPTION: A) Received in formalin designated "right mid transmetatarsal amputation" is a distal right foot including second, fourth, and fifth toes, measuring 9.0 x 9.0 x 4.0 cm. Also in the container is a piece of tan bone measuring 2.4 x 1.3 x 1.3 cm. The skin and subcutaneous tissue recedes up to 4.0 cm from the smooth bony margins of resection. The skin is tan-white. The first and third toes are missing. The remaining toes are slightly flexed and with a thickened irregular nail of the second toe. There is a round, deep ulcer at the bottom of the foot proximal to the second toe, measuring 1.5 x 1.5 x 0.7 cm. No other lesions are identified. The piece of bone is submitted for decalcification. Representative sections are submitted in A1 and A2, including skin and soft tissue margins. FINAL DIAGNOSIS: A) Right foot, mid-transmetatarsal amputation: 1. Right foot with ulceration 2. Status post amputation of first and third toes. 3. Skin and soft tissue margins histologically viable. 4. Bone section pending decalcification, addendum report to follow. COMMENT: Geographic fibrinoid necrosis associated with ulcer raises the possibility of a rheumatoid nodule. MICROSCOPIC DESCRIPTION: Microscopic examination was performed. Findings of decalcified specimen (A3). Sections of the bone demonstrate chronic reactive changes. No evidence of active osteomyelitis is identified. What are the CPT® and ICD-10-CM codes?

88367 88373 R87.619

CASE 2 SURGICAL PATHOLOGY ORDERING PHYSICIAN: Karen Smith, MD PROCEDURES: Surgical pathology procedure performed by a pathologist. CLINICAL INDICATIONS: Patient presents to her gynecologist for follow-up of an abnormal Papanicolaou (Pap) smear. (Diagnosis used for lab.) The physician refers patient for repeat Pap smear. The specimen is sent for interpretation and report by the pathologist providing consultative services. SPECIMENS: Pap smear, cervix. METHODOLOGY: Morphometric analysis Fluorescent In Situ Hybridization (FISH) using computer-assisted technology, professional component. (Procedure performed.) RESULTS: The pathologist reviews images from the slides. The pathologist does not identify any copies of the 3q26 (Initial stain.) and 5p15 (Additional stain.) genes in the stained slide images. This report is consistent with the patient's HPV results and the patient is not at presently at risk to develop severe dysplasia. A 41 year-old female presents to her gynecologist to review her abnormal Pap results. The physician reviews her Pap results which indicates that this patient is at risk for cervical cancer. The gynecologist recommends the patient have a repeat Pap smear and FISH studies to evaluate the tissue for the 3q26 and 5p15 genes which are associated with increased risk to develop cervical dysplasia. FISH studies may be ordered by gynecologist to evaluate the presence of copies of the 3q26 and 5p15 genes. The presence of these genes is associated with an increased risk to develop severe cervical dysplasia, and place the patient at a higher risk to develop invasive cervical cancer. The patient decides to have these studies and the physician performs a Pap smear on the same day. The specimen is sent for both HPV testing and probe studies for the 3q26 and 5p15 genes. Pathologist does the review and the interpretation and report of the FISH probes and reports that the probes 3q26 and 5p15 are not present in this patient's cervical Pap smear specimen. Referring physician sends the patient's Pap smear results and FISH studies which include the pathologist's interpretation and report. What are the CPT® and ICD-10-CM codes reported?

88323 C01

CASE 3 Requesting Provider: CI, MD SURGICAL PATHOLOGY REPORT Collected: Received: 3/4/2011, the pathologist providing the service is an employee of the lab. Materials Received for Consultation: Three referred specimens described as left base of tongue, left tonsil and right tonsil (There are three specimens.) CLINICAL DATA: Slides are prepared and reviewed in conjunction with the patient being seen for Radiation Oncology consultation for carcinoma of base of tongue (Use this diagnosis as consultation on referred materials is negative.) FINAL DIAGNOSIS: Eight slides prepared and reviewed A - H Left base of tongue (part A) and right tonsil, biopsies (parts B, C, G): Squamous mucosa and tonsillar tissue; no carcinoma identified. Left tonsil, biopsies (parts D, E, F, H): Tonsillar tissue with no carcinoma identified. (A total of eight slides are prepared and reviewed for a single case.) What are the CPT and ICD-10-CM codes

80048 85027 Z00.00

CASE 4 CLINICAL INDICATIONS: The patient is a 28 year-old female for routine lab tests part of her yearly physical exam. COLLECTED: 04/14/XX 13:29 PATIENT NUMBER: xxxxxxxxxxxxx ID: verified SITE: right antecubital venipuncture DISPOSITION: outpatient, fasting TEST: metabolic (Metabolic Panel is a set of tests performed as a panel in CPT®. Review the two metabolic panels to see if one includes the tests performed.) & CBC (CBC is not included in either metabolic panels and is reported separately.) RESULTS: SODIUM BLOOD: 141 mEq/L (135-145) POTASSIUM BLOOD: 4.0 mEq/L (3.3-4.8) CHLORIDE BLOOD: 105 mEq/L (95-105) CARBON DIOXIDE BLOOD: 24 mmol/L (23-30) UREA NITROGEN BLOOD: 12 mg/dL (5-25) CREATININE BLOOD: 0.86 mg/dL (0.70-1.50) GLUCOSE BLOOD: 93 mg/dL (70-110) CALCIUM BLOOD (TOTAL): 9.3 mg/dL (8.5-10.5) (The calcium is total instead of ionized.) CBC: (automated) (CBC is automated with no differential.) WBC: 6.9 thou/uL (3.9-10.3) HEMOGLOBIN BLOOD: 14.5 g/dL (11.8-16.0) PLATELET COUNT: 235 thou/uL (135-370) RED BLOOD CELLS: 5.02 mil/uL (4.00-5.50) IMPRESSION: Normal labs HCT: 40% (38%-46%) What are the CPT® and ICD-10-CM codes for the pathologist?

88104 E10.22 N18.6 Z99.2

CASE 5 Requested by R Simon, MD CYTOLOGY (Report indicates type of procedure performed.) REPORT Collected: 1/26/2011 Received: 1/27/2011, Pathologist performing the service is an employee of the lab. SPECIMEN SOURCE: A. Peritoneal Fluid SPECIMEN DESCRIPTION: 100mls yellow fluid CYTOPREPARATION: 2 ccf PERTINENT CLINICAL DATA AND CLINICAL DIAGNOSIS: 26 year-old female with end-stage renal disease (ESRD) due to type 1 diabetes presents for elective kidney transplant. (Use clinical diagnostic information to assign ICD-10-CM codes because the findings are negative.) CYTOLOGIC IMPRESSION: Peritoneal dialysis drain fluid: No cytologically malignant cells are identified. (Cytology is performed on the fluid obtained.) COMMENT: 100 mls yellow fluid is received from which two Papanicolaou stained cytocentrifuged slides are made. Slides contain mesothelial cells with a spectrum of reactive changes and histiocytes. No malignant cells are identified. What are the CPT® and ICD-10-CM codes?

88307 88300 T86.19 N28.0

CASE 6 Requested by R Williams, MD SURGICAL PATHOLOGY REPORT Collected: 2/1/20XX Received: 2/2/20XX. The pathologist is employed by the lab providing the service. CLINICAL DATA: 26 year-old with end-stage renal disease(ESRD) due to type 1 diabetes, status post kidney, pancreas transplant with subsequent pancreas allograft removal, now with disseminated intravascular coagulation and decreased urine output and kidney allograft showing no flow to the kidney. GROSS DESCRIPTION: A) Received fresh designated "ureteral stent - gross only" is a 15 cm x 0.2 cm piece of plastic tubing with a 1.5 cm hairpin turn at either end. There are 0.05 cm holes at every 2 cm of the device. B) Received fresh in a container labeled "removed kidney-gross and micro" is a 138 gram, 11 x 7 x 3 cm kidney. The specimen has a smooth, glistening, pink capsule with lightly adherent fibrous tissue. There are multiple surgical clips within the hilum and perihilar fat. The specimen is bivalved to reveal a sharp but irregular demarcation at the cortex and the medullary interface. No masses, nodules or lesions are grossly appreciated. There is probable intravascular thrombus. Representative sections are submitted as follows: B1 - renal vein, renal artery and ureteral margins; B2-B5 - representative sections of kidney parenchyma in relation to capsule. FINAL DIAGNOSIS: A) Medical device, removal: Pigtail catheter (gross only). B) Kidney, allograft resection: 1. Widespread acute coagulative necrosis/infarct of renal parenchyma in the setting of multifocal microvascular thrombi (clinical history of disseminated intravascular coagulation). 2. Focal renal arterial thrombosis. 3. No evidence of humoral or cellular rejection. What are the CPT® and ICD-10-CM codes ?

87102 87102-59 87103 87103-59 J18.9 R60.1 R31.9

CASE 7 Clinical Indications: Inpatient day 32 in ICU with fever, hematuria, generalized edema, pneumonia URINE FUNGAL CULTURE - Urine Special Requests: None Culture: No fungus isolated in 30 days LOWER RESP FUNGAL W/DIR. EXAM - Sputum Special Requests: None Stain for Fungus: No fungi seen Culture: One colony Candida albicans BLOOD FUNGAL CULTURE - Blood Arm, Right Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks BLOOD FUNGAL CULTURE - Blood Right IJ Catheter SWAN Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks What are the CPT® and ICD-10-CM codes?

88321 C7A.1

CASE 9 Requested by P Norris, MD SURGICAL PATHOLOGY REPORT MATERIALS RECEIVED: Referred slides of inguinal lymph node CLINICAL DATA: History of Merkel cell carcinoma. FINAL DIAGNOSIS: Lymph node, left inguinal, excision: 1. High grade neuroendocrine carcinoma involving one of four lymph nodes (1/4); see Comment. 2. No extranodal extension identified. COMMENT: The neoplasm consists of sheets of small round blue cells with powdery chromatin, scant cytoplasm, and indistinct cell borders. Numerous mitotic figures and areas of single cell necrosis are seen. The morphologic findings are consistent with a high grade neuroendocrine carcinoma and the differential diagnoses include metastatic Merkel cell carcinoma or small cell carcinoma. Given the patient's reported history (slides not reviewed at UMMM), the features are consistent with metastatic Merkel cell carcinoma. Correlation with clinical findings is advised. What are the CPT® and ICD-10-CM codes?