CPC Chapter 18- Pathology/Laboratory Practical Flashcards
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?
87641
A49.02
Response Feedback:
There is one CPT® code and one ICD-10-CM code reported. The test is performed to detect if the patient has MRSA. The method used is nucleic acid sequence. From the CPT® Index, look for Infectious Agent/Antigen Detection/Nucleic Acid Probe and narrow your search of codes by the infectious agent. Make sure to read the parenthetical statement below the CPT® code. The diagnosis is reported with the results from the Culture. In the ICD-10-CM Alphabetic Index look for Infection/methicillin/resistant Staphylococcus aureus (MRSA).
CASE 2
Requesting Provider: CI, MD
SURGICAL PATHOLOGY REPORT Collected: Received: 3/4/20XX, 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
88323
C01
Response Feedback:
There is one CPT® code and one ICD-10-CM code reported. This is a surgical pathology consultation with preparation of slides (the consultant prepares the referred slides). A consultation of referred slides is reported per consultation; not how many specimens were reviewed. In the CPT® Index look for Consultation/Surgical Pathology. The indication is carcinoma of base of tongue and supports the medical necessity of the consultation. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/tongue/base/Malignant Primary.
CASE 3
Requested by P Norris, MD
SURGICAL PATHOLOGY REPORT
MATERIALS RECEIVED:
Referred slides of inguinal lymph node(Consultation on referred slides.)
CLINICAL DATA: History of Merkel cell carcinoma.
FINAL DIAGNOSIS:
Lymph node, left inguinal, excision:
- High grade neuroendocrine carcinoma(This is the only definitive diagnosis reported.) involving one of four lymph nodes (1/4); see Comment.
- 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.(Even though these diagnoses are given in the differential diagnoses, the final diagnosis indicates a specific malignant carcinoma, so this is coded.) 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?
88321
C7A.1
Response Feedback:
There is one CPT® code and one ICD-10-CM codes reported. This surgical pathology consultation is similar to Case 3. The difference is that the referred slides were prepared elsewhere. From the CPT® Index, look for Consultation/Surgical Pathology. The Final Diagnosis indicates high grade neuroendocrine carcinoma and is the definitive diagnosis. In the ICD-10-CM Alphabetic Index look for Carcinoma/neuroendocrine/high grade, any site. Validate the code in the Tabular List.
CASE 4
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 from the Pap smear probes 3q26 and 5p15 are not present in this patient’s cervical Pap smear specimen.
Referring physician sends the patient’s results of the FISH studies which include the pathologist’s interpretation and report.
What are the CPT® and ICD-10-CM codes reported?
88367, 88373
R87.619
Response Feedback:
There are two CPT® codes and one ICD-10-CM code reported. This is a Fluorescent in Situ Hybridization (FISH) with two stains. In the CPT® Index, look for Fluorescent in Situ Hybridization (FISH)/Probe/Morphometric Analysis Computer-Assisted and for the code range. The indication for the tests is an abnormal Papanicolaou (Pap) smear. In the ICD-10-CM Alphabetic Index look for Abnormal/Papanicolaou (smear)/cervix.
CASE 5
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?
80048, 85027
Z00.00
Response Feedback:
There are two CPT® codes and one ICD-10-CM code reported. A Basic Metabolic Panel and automated CBC were performed as a part of a yearly physical exam. The lab panel is indexed in CPT® under Blood Tests/Panels/Metabolic/Basic. The CBC is the second code and is indexed under Blood Cell Count/Complete (CBC). In the ICD-10-CM Alphabetic Index look for Examination/laboratory (as part of a general medical examination).
CASE 6
Requested by R Simon, MD
CYTOLOGY REPORT Collected: 1/26/20XX Received: 1/27/20XX, 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.
CYTOLOGIC IMPRESSION:
Peritoneal dialysis drain fluid: No cytologically malignant cells are identified.
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?
88108
E10.22, N18.6, Z99.2
Response Feedback:
There is one CPT® code and three ICD-10-CM codes reported. The test is a cytopathology evaluation of specimen smears from peritoneal fluid. In the CPT® Index look for Cytopathology/Smears/Concentration Technique. The clinical diagnoses are ESRD due to type 1 diabetes. In the ICD-10-CM Alphabetic Index locate Diabetes/type 1/with/chronic kidney disease. There is a Use additional code note to identify the stage of kidney disease (ESRD). The ESRD code also has a Use additional code note to identify the dialysis status.
CASE 7
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:
- Right foot with ulceration
- Status post amputation of first and third toes.
- Skin and soft tissue margins histologically viable.
- 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?
88307, 88311
L97.511
Response Feedback:
There are two CPT® codes and one ICD-10-CM code reported. Surgical pathology of gross and microscopic examination is performed on two specimens from toes and bone. There is only one CPT® code reported for the gross and microscopic examination for both specimens because both specimens were placed in one container. It is important to note this is a non-traumatic amputation of the mid transmetatarsal (or midfoot). Decalcification is reported separately as the second procedure code. It is an add-on code and modifier 51 exempt. The reason for the tests is indicated as an ulceration of the right foot. In the ICD-10-CM Alphabetic Index look for Ulcer/lower limb/foot specified NEC/right/with skin breakdown only. Validate the code in the Tabular List.
CASE 8
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:
- Widespread acute coagulative necrosis/infarct of renal parenchyma in the setting of multifocal microvascular thrombi (clinical history of disseminated intravascular coagulation).
- Focal renal arterial thrombosis.
- No evidence of humoral or cellular rejection.
What are the CPT® and ICD-10-CM codes ?
88307, 88300
T86.19, N28.0
Response Feedback:
There are two CPT® codes and two ICD-10-CM codes reported. A surgical pathology service is performed on two specimens from the ureteral stent and the kidney. Look in CPT® for Surgical Pathology/Gross and Microscopic Exams. The first code is for the gross and microscopic exam of the kidney (Level V). Only a gross exam (Level I) of the ureteral stent was done which is reported as the second code. The indication for the pathology services is a complication of a kidney transplant and listed as the first diagnosis. In ICD-10-CM Alphabetic Index look for Complication(s) (from) (of)/transplant/kidney/specified type NEC. An additional diagnosis for renal artery thrombosis is the second diagnosis. Look in the Alphabetic Index for Thrombosis/renal/artery.
CASE 9
Requested by D Freeman, MD
SURGICAL PATHOLOGY REPORT Collected: 4/20/20XX Received: 4/20/20XX. The pathologist providing the service is an employee of the lab.
CLINICAL DATA: Post-heart transplant, rule out rejection.
GROSS DESCRIPTION:
A) Received in a scant amount of formalin labeled “right ventricle endomyocardium” are seven tan-brown, irregular soft tissues averaging 0.1 cm in greatest dimension. The specimen is submitted in toto in cassette A1.
B) Received in a vial of immunofluorescence fixative labeled “right ventricle endomyocardium” are two tan, irregular soft tissues averaging 0.1 cm in greatest dimension. Specimen is entirely submitted for immunofluorescence.
MICROSCOPIC DESCRIPTION:
A) Sections of the paraffin-embedded material show six fragments of myocardium which are adequate to evaluate. There are few mononuclear cells present within the tissue, but these are beneath the threshold required to diagnose biologically meaningful rejection.
No cell injury is seen and no inclusion bodies are noted.
B) Sections of the frozen myocardium demonstrate two fragments of myocardium and one fresh blood clot. There is no inflammatory cell infiltrate.
IMMUNOFLUORESCENCE REPORT:
Tissue, received in transport media, is washed in buffer and snap frozen in liquid nitrogen-cooled isopentane. Acetone-fixed frozen sections of the snap-frozen tissue are incubated with fluorescein-conjugated polyclonal antibodies to IgG, IgM, IgA, C3, C1q, fibrinogen, and albumin. Localization is thus via direct immunofluorescence. Indirect immunofluorescence staining of peritubular capillaries for C4d.
Results are as indicated below:
Block (Original Label): B Population: Microvascular endothelium
FINAL DIAGNOSIS:
A, B) Right ventricular endomyocardial biopsy:
- No significant cellular rejection.
- Immunofluorescence studies positive for humoral/vascular rejection (IgM and complement present). Please see comment.
COMMENT:
A, B) This is the 4th biopsy since transplant. Compared to his most recent biopsy, the current specimen shows no change in the degree of cellular rejection.
What are the CPT® and ICD-10-CM codes?
88307X2, 88346, 88350X7
T86.21
Response Feedback:
There are three CPT® codes and one ICD-10-CM code reported. The first code is surgical pathology on two specimens obtained from the endomyocardium and sent for a gross and microscopic exam. Look in the CPT® for Surgical Pathology/Gross and Microscopic Exams (level V). The second and third codes are for the Immunofluorescent study for a total of 8 antibodies tested. In the CPT® Index look for Immunofluorescence Microscopy/Antibody Stain Procedure for the code choices. The Final Diagnosis indicates that one of the lab tests is positive for rejection of the heart transplant which is the diagnosis. In the ICD-10-CM Alphabetic Index look for Rejection/transplant/heart.
CASE 10
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?
87102, 87102-59, 87103, 87103-59
J18.9, R60.1, R31.9
Response Feedback:
There are four CPT® codes and three ICD-10-CM codes reported. There are four specimens obtained to perform cultures. The first two codes are for the urine and sputum cultures. In the CPT® Index look for Culture/Fungus/Source Other than Blood. You will need to report the code twice with a modifier on the second code to indicate a distinct service. CPT® codes three and four report two cultures obtained from blood from two different sites. In the Index locate Culture/Fungus/Blood. You will need to report the code twice with a modifier on the fourth code to indicate a distinct service. The CPT® subsection guidelines of Microbiology indicate which modifier to report for multiple specimens. The first diagnosis is pneumonia. In the ICD-10-CM Alphabetic Index look for Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved). Fever is a symptom of pneumonia and not coded (guideline section 1.B.4). Generalized Edema is the second diagnosis. Look in the Alphabetic Index for Edema, edematous (infectious) (pitting) (toxic)/generalized. Hematuria is the third diagnosis and is found by looking in the Alphabetic Index for Hematuria.
