Diagnosis: Stomach (distal): Invasive adenocarcinoma
Gross description: Received in formalin two specimens, 9.0- × 5.5- × 4.3- cm and 2.0- × 1.5- × 3.4-cm segments of the stomach, with a palpable firm 3.0- × 2.5-cm mass on the designated lesser curvature of the larger specimen. The external surfaces of the specimens are unremarkable and inked black. The curved surfaces demonstrate the mass and adjacent firm areas of nodularity. The remainder of the gastric mucosa is unremarkable.
Microscopic description: Microscopic examination was performed. See synoptic report.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

C16.5 is the ICD-10-CM code for malignant neoplasm of the lesser curvature of the stomach, unspecified, which matches the location described in the diagnosis. The CPT code 88309 is used for the pathological examination of specimens that require a gross and microscopic examination, such as invasive adenocarcinoma of the stomach. The "x2" indicates that two specimens were examined, which aligns with the gross description provided.

Diagnosis: Stomach (Distal): Invasive Adenocarcinoma