LOCATION: Inpatient, Hospital PATIENT: Beverly Hill ATTENDING PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD PATHOLOGIST: Grey Lonewolf, MD…

LOCATION: Inpatient,

Hospital PATIENT: Beverly Hill ATTENDING

PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD

PATHOLOGIST: Grey Lonewolf, MD CLINICAL

HISTORY: Mass left atrium.

SPECIMEN RECEIVED: Myxoma—left atrium with FS.

GROSS DESCRIPTION: The specimen is labeled with the patient’s name and “left atrial myxoma,” and consists of a 4 × 2 × 2 cm ovoid mass with a partially calcified hemorrhagic white-tan tissue. INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Myxoma, per Dr. Lonewolf. MICROSCOPIC DIAGNOSIS: Sections show a well-circumscribed mass consisting of fibromyxoid tissue showing numerous vascular channels. Areas of superficial ulceration and chronic inflammatory infiltrate are noted. Areas of calcification are also present. DIAGNOSIS: Myxoma, benign, left atrium.

Abstracting & Coding Questions: 

1. The Specimen Received section indicates “FS.” What does FS stand for?

2. Is the intraoperative FS reported separately?

3. What CPT code(s) would be reported for this case?

4. What ICD-10-CM code(s) would be reported for this case? 

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