Question

Code the following reports utilizing CPT codes, apply any application modifiers

1. Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.

GROSS DESCRIPTION:
A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an
8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x
0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.
B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.
C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x
14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.
D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.
E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a
2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .

FINAL DIAGNOSIS:
A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.
C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma
(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.
D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.
E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.

COMMENTS: Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.

Answer 1

CPT stands for Current Procedural Terminology listing of codes for reporting services and procedures performed by providers and other health care professionals and

CPT modifier is a two digit alpha, numeric or alphanumeric characters added to CPT codes when additional information needs to be communicated pertaining to a procedure or service

or

CPT modifier is a two digit code that is appended to the CPT code to indicate that a service or procedure has been altered for some reason but that the main definition of the code has not changed.

Here in the present scenario, we can see the Biopsy description of lungs

Thus we can assign the CPT code for

Biopsy of the lung as Lung Biopsy: 32405

Biopsy of Lymph nodes: 38505

Here we can apply the CPT modifier 22, that is; Increased procedural services (POSSIBLY ON TEST)