Specimen site: Right medial cheek
Specimen site: Left dorsal hand
Gross description: Right medial cheek: The specimen is one gray-white fragment measuring 0.3 × 0.2 cm. Totally submitted in one cassette with a request for levels labeled "A."
Left dorsal hand: The specimen is one gray-white fragment measuring 0.3 × 0.3 cm. Totally submitted in one cassette with a request for levels labeled "B."
Microscopic description: The right medial cheek shows atypical keratinocytes within the entire thickness of the epidermis extending to the stratum corneum. The lesion appears to have been excised. The dermis shows elastosis.
The dorsal hand shows hyperkeratosis. The epidermis is mildly acanthotic. There is extensive dermal elastosis.
Final diagnoses:
1) Right medial cheek, biopsy:
? Squamous cell carcinoma in-situ. (See comment.)
2) Left dorsal hand, biopsy:
? Dermal elastosis.
? No malignant changes seen.
Comment: The lesion from the cheek appears to reside within the confines of the histologic section. The skin lesion shows no invasive malignancy.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM codes are D04.39 for the squamous cell carcinoma in-situ of the right medial cheek and L87.2 for the dermal elastosis of the left dorsal hand. The correct CPT code is 88305 x2 because two separate specimens (right medial cheek and left dorsal hand) were submitted for histopathological examination, each requiring its own level sectioning as indicated by the requests for levels labeled "A" and "B".

Specimen Site: Right Medial Cheek