Case
-T12-2B PATHOLOGY REPORT
LOCATION: Inpatient, Hospital
PATIENT: Kenny Jetty
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Lower back pain due to herniated disc
SPECIMEN RECEIVED: Disc, lumbar 4-5
GROSS DESCRIPTION: Submitted in formalin, labeled with the patient's name and "disc lumbar 4-5," are multiple fragments of ragged tan tissue measuring 7 3.5 1 cm (centimeter) in aggregate. Representative fragments are in one cassette.
MICROSCOPIC DIAGNOSIS: Intervertebral disc, L4-5, discectomy: Fibrocartilaginous intervertebral disc fragments.
T12-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 88304 (Pathology, Surgical, Gross and Micro Exam, Level III)
ICD-10-CM DX: M51.26 (Displacement/displaced, intervertebral disc, lumbar region)
Explanation: The service is pathological examination of an intervertebral disc and in the code description for 88304 "Intervertebral Disc" is listed, so the correct code is 88304.
The Postoperative Diagnosis is stated to be herniated disc and is reported with M51.26.

Case -T12-2B PATHOLOGY REPORT