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A patient undergoes outpatient surgery. A skin lesion of the cheek is surgically removed and submitted to the pathologist for analysis. The surgeon writes on the pathology order, “skin lesion.”...
The patholog...
A patient presents to the hospital for outpatient x-rays with a diagnosis on the physician’s orders of questionable kidney stone. The abdominal x-ray reveals “bilateral nephrolithiasis with sta...
It is correc...
A patient undergoes outpatient surgery for removal of a right breast mass. The pre- and post-operative diagnosis is reported as “breast mass.” The pathological diagnosis is fibroadenoma. How sh...
The facility...
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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