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

The correct ICD-10-CM code for invasive adenocarcinoma of the distal stomach is C16.5. The CPT codes 88309 x2 are appropriate because two separate specimens from the stomach were examined, each requiring a complex (Level V) pathology examination.

Diagnosis: Stomach (Distal): Invasive Adenocarcinoma