Widespread acute coagulative necrosis/infarct of renal parenchyma in the setting of multifocal microvascular thrombi (clinical history of disseminated intravascular coagulation).ģ. Representative sections are submitted as follows: B1 - renal vein, renal artery and ureteral margins B2-B5 - representative sections of kidney parenchyma in relation to capsule.Ī) Medical device, removal: Pigtail catheter (gross only).ġ. There is probable intravascular thrombus. No masses, nodules or lesions are grossly appreciated. The specimen is bivalved to reveal a sharp but irregular demarcation at the cortex and the medullary interface. There are multiple surgical clips within the hilum and perihilar fat. The specimen has a smooth, glistening, pink capsule with lightly adherent fibrous tissue. There are 0.05 cm holes at every 2 cm of the device.ī) Received fresh in a container labeled "removed kidney-gross and micro" is a 138 gram, 11 x 7 x 3 cm kidney. The pathologist is employed by the lab providing the service.ĬLINICAL DATA: 26 year-old with end-stage renal disease(ESRD) due to type 1 diabetes, status post kidney, pancreas transplant with subsequent pancreas allograft removal, now with disseminated intravascular coagulation and decreased urine output and kidney allograft showing no flow to the kidney.Ī) Received fresh designated "ureteral stent - gross only" is a 15 cm x 0.2 cm piece of plastic tubing with a 1.5 cm hairpin turn at either end. SURGICAL PATHOLOGY REPORT Collected: 2/1/20XX Received: 2/2/20XX. What are the CPT® and ICD-10-CM codes for the pathologist? Review the two metabolic panels to see if one includes the tests performed.) & CBC (CBC is not included in either metabolic panels and is reported separately.)ĬALCIUM BLOOD (TOTAL): 9.3 mg/dL (8.5-10.5) (The calcium is total instead of ionized.)ĬBC: (automated) (CBC is automated with no differential.) TEST: metabolic (Metabolic Panel is a set of tests performed as a panel in CPT®. SITE: right antecubital venipuncture DISPOSITION: outpatient, fasting What are the CPT® and ICD-10-CM codes reported?ĬLINICAL INDICATIONS: The patient is a 28 year-old female for routine lab tests part of her yearly physical exam.ĬOLLECTED: 04/14/XX 13:29 PATIENT NUMBER: xxxxxxxxxxxxx ID: verified Referring physician sends the patient's Pap smear results and FISH studies which include the pathologist's interpretation and report. Pathologist does the review and the interpretation and report of the FISH probes and reports that the probes 3q26 and 5p15 are not present in this patient's cervical Pap smear specimen. The specimen is sent for both HPV testing and probe studies for the 3q26 and 5p15 genes. The patient decides to have these studies and the physician performs a Pap smear on the same day. The presence of these genes is associated with an increased risk to develop severe cervical dysplasia, and place the patient at a higher risk to develop invasive cervical cancer. The gynecologist recommends the patient have a repeat Pap smear and FISH studies to evaluate the tissue for the 3q26 and 5p15 genes which are associated with increased risk to develop cervical dysplasia.įISH studies may be ordered by gynecologist to evaluate the presence of copies of the 3q26 and 5p15 genes. The physician reviews her Pap results which indicates that this patient is at risk for cervical cancer. This report is consistent with the patient's HPV results and the patient is not at presently at risk to develop severe dysplasia.Ī 41 year-old female presents to her gynecologist to review her abnormal Pap results. The pathologist does not identify any copies of the 3q26 (Initial stain.) and 5p15 (Additional stain.) genes in the stained slide images. RESULTS: The pathologist reviews images from the slides. METHODOLOGY: Morphometric analysis Fluorescent In Situ Hybridization (FISH) using computer-assisted technology, professional component. The specimen is sent for interpretation and report by the pathologist providing consultative services. (Diagnosis used for lab.) The physician refers patient for repeat Pap smear. PROCEDURES: Surgical pathology procedure performed by a pathologist.ĬLINICAL INDICATIONS: Patient presents to her gynecologist for follow-up of an abnormal Papanicolaou (Pap) smear.
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