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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777 Exercise 2
Case 4-2
LOCATION: Inpatient, Hospital
PATIENT: Beverly Hill
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Mass left atrium.
SPECIMEN RECEIVED: Myxoma-left atrium with FS.
GROSS DESCRIPTION: The specimen is labeled with the patient's name and "left atrial myxoma," and consists of a 4 × 2 × 2 cm ovoid mass with a partially calcified hemorrhagic white-tan tissue.
INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Myxoma, per Dr. Lonewolf.
MICROSCOPIC DIAGNOSIS: Sections show a well-circumscribed mass consisting of fibromyxoid tissue showing numerous vascular channels. Areas of superficial ulceration and chronic inflammatory infiltrate are noted. Areas of calcification are also present.
DIAGNOSIS: Myxoma, benign, left atrium.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. The Specimen Received section indicates "FS." What does FS stand for? _________________
2. Is the intraoperative FS reported separately? _________________
LOCATION: Inpatient, Hospital
PATIENT: Beverly Hill
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Mass left atrium.
SPECIMEN RECEIVED: Myxoma-left atrium with FS.
GROSS DESCRIPTION: The specimen is labeled with the patient's name and "left atrial myxoma," and consists of a 4 × 2 × 2 cm ovoid mass with a partially calcified hemorrhagic white-tan tissue.
INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Myxoma, per Dr. Lonewolf.
MICROSCOPIC DIAGNOSIS: Sections show a well-circumscribed mass consisting of fibromyxoid tissue showing numerous vascular channels. Areas of superficial ulceration and chronic inflammatory infiltrate are noted. Areas of calcification are also present.
DIAGNOSIS: Myxoma, benign, left atrium.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. The Specimen Received section indicates "FS." What does FS stand for? _________________
2. Is the intraoperative FS reported separately? _________________
Explanation
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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
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