Specimen site: Gastric biopsy
Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels.
Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive.
Final diagnosis:
Gastric biopsy:
? Chronic active gastritis.
? Warthin-Starry stain positive for H. pylori.
? Negative for intestinal metaplasia, dysplasia, or malignancy.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct diagnosis is chronic active gastritis with H. pylori infection, which is coded as K29.50 in ICD-10-CM for chronic gastritis without bleeding and B96.81 for H. pylori as a cause of diseases classified elsewhere. The CPT codes 88305 for the tissue examination and 88312 for the special stain (Warthin-Starry stain) used to identify H. pylori are appropriate, indicating the procedures performed on the biopsy specimen.

Specimen Site: Gastric Biopsy