Instructions: Assign the ICD-10 and CPT/HCPCS codes for this surgical pathology case study.
These are the codes I assigned but I’m not sure if they are correct.
|Clinical Impression: GI bleed, r/o sprue, H. pylori|
Part A-Received labeled small bowel in formalin are fragments of tissue collectively measuring about 1 cm in greatest dimension processed entirely. One block.
Part B-Received labeled gastric in formalin are fragments of tissue collecting measuring about 0.8 cm in greatest dimension processed entirely. One block.
Part A-Duodenal mucosa shows an intact villous architecture without increased intraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, active inflammation or Giardia are identified.
Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlying gastric glands with lamina propria showing fibromuscular tissue with scattered chronic inflammatory cells. No intestinal metaplasia is identified.
Warthin-Starry stain reveals no Helicobacter pylori forms.
Part A-Small bowel, duodenum biopsy No diagnostic abnormality
Part B-Stomach, biopsy
Mild chronic gastritis