whitefield13
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Hi all,
I am looking for the surgical pathology, gross and microscopic examination codes for the specimens A and B:
Report:
A. “Finger”: Received is a 0.5 x 0.4 x 0.1 cm tank skin fragment that demonstrates a 0.2 cm blue-gray slightly raised lesion. The margin of resection is inked black.
B. “L arm”: received is a 0.6 x 0.5 x 0.2 cm tan skin fragment. The margin of resection is inked black.
Microscopic:
A. Epidermis shows hyperkeratosis with focal parakeratosis. There is an area of hemorrhage in the deepest portion of the stratum corneum. Cellular portion of the epidermis shows some reactive changes. Mild actinic degeneration is seen in dermal collagen.
B. Overlying epidermis is focally ulcerated. The dermis contains numerous irregular nests of malignant basal cells, many of which remain attached to the overlying epidermis. Surgical margins are free of tumor.
Diagnosis:
A. Left fifth finger: Hyperkeratotic skin with intracorneal hemorrhage.
B. Left arm: Basal cell carcinoma, margins free of tumor.
I came up with the code 88305. Looks like both specimens are to be coded as surgical pathology - skin other than cyst/tag/debridement/plastic repair. Am I right on this? Kindly give feedback.
Thanks!
I am looking for the surgical pathology, gross and microscopic examination codes for the specimens A and B:
Report:
A. “Finger”: Received is a 0.5 x 0.4 x 0.1 cm tank skin fragment that demonstrates a 0.2 cm blue-gray slightly raised lesion. The margin of resection is inked black.
B. “L arm”: received is a 0.6 x 0.5 x 0.2 cm tan skin fragment. The margin of resection is inked black.
Microscopic:
A. Epidermis shows hyperkeratosis with focal parakeratosis. There is an area of hemorrhage in the deepest portion of the stratum corneum. Cellular portion of the epidermis shows some reactive changes. Mild actinic degeneration is seen in dermal collagen.
B. Overlying epidermis is focally ulcerated. The dermis contains numerous irregular nests of malignant basal cells, many of which remain attached to the overlying epidermis. Surgical margins are free of tumor.
Diagnosis:
A. Left fifth finger: Hyperkeratotic skin with intracorneal hemorrhage.
B. Left arm: Basal cell carcinoma, margins free of tumor.
I came up with the code 88305. Looks like both specimens are to be coded as surgical pathology - skin other than cyst/tag/debridement/plastic repair. Am I right on this? Kindly give feedback.
Thanks!
