CHAPTER 4: PATHOLOGY AND LABORATORY 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: 1. What is a serum HCG?
1. Serum HCG test is done check the hormone called human chorionic gonadotropin in your blood. HCG is a hormone normally produced during pregnancy.
ICD-10-CM code for dysfunction uterine bleeding is N93.8
CPT code for endometrial curettage is 58558.
CHAPTER 4: PATHOLOGY AND LABORATORY Case 4-1 LOCATION: Outpatient, Hospital PATIENT: Kimberly Lakeland ATTENDING PHYSICIAN: Ira...