The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Exercise 1

Case 4-1
LOCATION: Outpatient, Hospital
PATIENT: Kimberly Lakeland
ATTENDING PHYSICIAN: Ira Avila, MD
SURGEON: Ira Avila, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Dysfunctional uterine bleeding. Recent false-positive serum HCG, last delivery 1 year ago.
SPECIMEN RECEIVED: Endometrial curettings.
GROSS DESCRIPTION: Submitted in formalin and labeled with patient's name and "endometrial curettings" are multiple fragments of tan-brown tissue measuring approximately 3 cc in aggregate. Submitted in toto.
MICROSCOPIC DIAGNOSIS: The slide shows multiple fragments of endometrial tissue featuring an overall normal gland-to-stroma ratio. The glands are somewhat irregular and coiled, and the majority of glands feature subnuclear vacuoles. The stroma is mildly to moderately edematous and bland.
DIAGNOSIS: Uterus, endometrium, curettage; early secretory phase endometrium.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
What is a serum HCG? _________________