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A referring physician sends a urine specimen to the cytology lab for analysis with a diagnosis of “hematuria” (code R31.9). However, the cytology report, which is authenticated by the pathologi...
The laborato...
A patient presents to the physician’s office with complaints of urinary frequency and burning. The physician ordered a urinalysis and the findings were positive for bacteria and increased white b...
Since this t...
The physician refers a patient for chest x-ray to outpatient radiology with a diagnosis of weakness and chronic myelogenous leukemia (CML). The radiology report demonstrated no acute disease and mo...
The facility...
A patient presents to the doctor’s office with a complaint of fatigue. The physician orders a complete blood count (CBC). The CBC reveals a low hemoglobin and hematocrit. Should the lab report th...
The laborato...
A 55-year-old male underwent screening colonoscopy and a large polyp was found. Due to its size, and the inability of the gastroenterologist to visualize the base of the polyp, it was only partiall...
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The above patient returns to the gastrointestinal (GI) lab for repeat colonoscopy since the entire polyp could not be removed during the initial encounter. A polypectomy is carried out in which the...
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A patient, who is status post removal of adenomatous colon polyps five years ago, presents to the GI lab for surveillance colonoscopy. The colonoscopy is completely normal and the provider recommen...
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A patient is status post colon polypectomy for an adenomatous polyp. Because of the suspicious nature of the polyp and potential for malignant transformation, the patient is being seen for a follow...
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The patient had a history of hyperplastic colon polyp, which was found on a previous screening colonoscopy. Since a hyperplastic polyp is not neoplastic in nature, how should a history of hyperplas...
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What is the correct code assignment for personal history of rectal polyp in ICD-10-CM? There is no specific Alphabetic Index entry for personal history of rectal polyp in the classification. Would ...
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