MCCG 2620 Miami Dade College Health Professional Billing and Coding Discussion
Question 1 (300 words min.)
Review the patient case below, which will open in a new window. Then assign the corresponding CPT, ICD-10-CM, and/or HCPCS Level II codes and provide rationale for each.
SXP01- Williams, Carrie (Attached below in document)
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Question 2 (300 words min.)
Review the patient case below, which will open in a new window. Then assign the corresponding CPT, ICD-10-CM, and/or HCPCS Level II codes and provide rationale for each. MCCG 2620 Miami Dade College Health Professional Billing and Coding Discussion
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SXP04-Grier, Carol (Attached below in document)
Surgical Pathology
Patient Case Number: SXP01-Williams, Carrie
Patient Name: Carrie Williams DOB: 02-10-75 Sex: F
Submitting Physician
Brandon Smith, MD
Attending Physician
Nancy Smalls, MDCollected Date/Time
09-07-XX 11:20AM
Received Date/Time
09-07-XX 11:30AMAccession Number: HL-11-34574
Clinical Summary/Clinical Impression: GI bleed, r/o sprue, H. pylori
Gross Description:
Part A-Received labeled small bowel in formalin are fragments of tissue collectivelymeasuring about 1 cm in greatest dimension processed entirely. One block.
Part B-Received labeled gastric in formalin are fragments of tissue collecting measuringabout 0.8 cm in greatest dimension processed entirely. One block.
Microscopic Description:
Part A-Duodenal mucosa shows an intact villous architecture without increasedintraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, activeinflammation or Giardia are identified.
Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlyinggastric glands with lamina propria showing fibromuscular tissue with scattered chronicinflammatory cells. No intestinal metaplasia is identified. MCCG 2620 Miami Dade College Health Professional Billing and Coding Discussion
Warthin-Starry stain reveals no Helicobacter pylori forms.
Pathologic Diagnosis:
Part A-Small bowel, duodenum biopsy No diagnostic abnormality
Part B-Stomach, biopsy
Mild chronic gastritis
Surgical Pathology
Patient Case Number: SXP04-Grier, Carol
Patient Name: Carol Grier DOB: 12-22-63 Sex: F
Submitting Physician
Janet Dobson, MD
Attending Physician
Simon Powers, MDCollected Date/Time
04-01-XX 10:00AM
Received Date/Time
04-01-XX 10:15AMAccession Number: JP-485-7741
Clinical Summary/Clinical Impression: R/O Candida
Gross Description:
The specimen consists of 25 ml. of hazy, colorless fluid with brush tip; two cytospin and onecell block preparation.
Microscopic Description:
The cytospin preparations consist of predominately many squamous cells and some fungalorganisms morphologically consistent with Candida species. The cell block shows similarfindings with less cellularity.
Diagnosis:
Esophageal brushings (cytospin and cell block preparations)
No cells are diagnostic for malignancy. Some fungal organisms morphologically consistentwith Candida species are present.
Electronically Signed By: Sharon Walker, MD . MCCG 2620 Miami Dade College Health Professional Billing and Coding Discussion
