Specimen site: Cervical biopsy
Pre-operative Diagnosis: Severe squamous dysplasia, consistent with CIN III (high-grade dysplasia)
Gross description: Cervical biopsy: One fragment of gray-white tissue, measuring 0.5 centimeters in diameter. Totally submitted with a request for levels. Submitted request for stains.
Microscopic description: Sections of the cervical biopsy show high-grade dysplasia, consistent with CIN III. No evidence of invasive malignancy is present.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct diagnosis code for severe squamous dysplasia, consistent with CIN III (high-grade dysplasia), is D06.9, which refers to carcinoma in situ of the cervix uteri, unspecified. The CPT code 88305 represents a level IV surgical pathology, gross and microscopic examination, which is appropriate for a cervical biopsy. There is no mention of a specific stain being performed in the provided information, so 88312 (special stains) is not applicable.

Specimen Site: Cervical Biopsy