Question 1 (300 words min.)
Review the patient case below, which will open in a new window. Then assign the corresponding CPT, ICD-10-CM, and/or HCPCS Level II codes and provide rationale for each.
SXP01- Williams, Carrie (Attached below in document)
_________________________________________________________
Question 2 (300 words min.)
Review the patient case below, which will open in a new window. Then assign the corresponding CPT, ICD-10-CM, and/or HCPCS Level II codes and provide rationale for each. 
SXP04-Grier, Carol (Attached below in document)
SXP01WilliamsCarrie
1 of 2
https://mybsc.bryantstratton.edu/bbcswebdav/pid-6308298-dt-content-ri…
Surgical Pathology
Patient Case Number: SXP01-Williams, Carrie
Patient Name: Carrie Williams
DOB: 02-10-75
Sex: F
Submitting Physician
Brandon Smith, MD
Collected Date/Time
09-07-XX 11:20AM
Accession Number: HL-11-34574
Attending Physician
Nancy Smalls, MD
Received Date/Time
09-07-XX 11:30AM
Clinical Summary/Clinical Impression: GI bleed, r/o sprue, H. pylori
Gross Description:
Part A-Received labeled small bowel in formalin are fragments of tissue collectively
measuring about 1 cm in greatest dimension processed entirely. One block.
Part B-Received labeled gastric in formalin are fragments of tissue collecting measuring
about 0.8 cm in greatest dimension processed entirely. One block.
Microscopic Description:
Part A-Duodenal mucosa shows an intact villous architecture without increased
intraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, active
inflammation or Giardia are identified.
Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlying
gastric glands with lamina propria showing fibromuscular tissue with scattered chronic
inflammatory cells. No intestinal metaplasia is identified.
Warthin-Starry stain reveals no Helicobacter pylori forms.
Pathologic Diagnosis:
Part A-Small bowel, duodenum biopsy No diagnostic abnormality
Part B-Stomach, biopsy
Mild chronic gastritis
Electronically Signed by: Peter Deutch, MD
Copyright © 2020 by The American Health Information Management Association. All Rights
Reserved.
4/8/2022, 2:43 AM
SXP01WilliamsCarrie
2 of 2
https://mybsc.bryantstratton.edu/bbcswebdav/pid-6308298-dt-content-ri…
4/8/2022, 2:43 AM
SXP04GrierCarol
1 of 1
https://mybsc.bryantstratton.edu/bbcswebdav/pid-6308298-dt-content-ri…
Surgical Pathology
Patient Case Number: SXP04-Grier, Carol
Patient Name: Carol Grier
DOB: 12-22-63
Submitting Physician
Janet Dobson, MD
Collected Date/Time
04-01-XX 10:00AM
Accession Number: JP-485-7741
Attending Physician
Simon Powers, MD
Received Date/Time
04-01-XX 10:15AM
Sex: F
Clinical Summary/Clinical Impression: R/O Candida
Gross Description:
The specimen consists of 25 ml. of hazy, colorless fluid with brush tip; two cytospin and one
cell block preparation.
Microscopic Description:
The cytospin preparations consist of predominately many squamous cells and some fungal
organisms morphologically consistent with Candida species. The cell block shows similar
findings with less cellularity.
Diagnosis:
Esophageal brushings (cytospin and cell block preparations)
No cells are diagnostic for malignancy. Some fungal organisms morphologically consistent
with Candida species are present.
Electronically Signed By: Sharon Walker, MD
Copyright © 2020 by The American Health Information Management Association. All Rights
Reserved.
4/8/2022, 2:45 AM

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