Wiki how would you could this?

[irishhawk]

Epidural phlegmon: dense fibroconnective tissue with acute and chronic inflammation and reactive synovium.
gross: 1.6x0.5x0.1 cm aggregate of multiple fragments of tan soft tissue

One person votes 88307. Anyone else care to chime in, please?
Thank you !

 

[mitchellde]

If you are coding for pathology and gross is all you have then you can only code 88300

 

[irishhawk]

If you are coding for pathology and gross is all you have then you can only code 88300

The first line is the microscopic diagnosis, followed by the gross.

 

[mitchellde]

The first line is the microscopic diagnosis, followed by the gross.

You will need more than the diagnosis to be able to code it as a microscopic, however assuming that there is sufficient documentation, I would code this as 88305 since it is described as fragments. If it were a mass it would be 88307. It is definitely not 88304.