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Lung: Click sections headings below (in blue) to expand or collapse the section content
Diagnostic Headings (i.e. specimen & procedure)
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Diagnostic Headings |
CPT Code |
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Left / Right lung, ___ lobe, core biopsy: |
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Left / Right lung, ___ lobe, transbronchial biopsy: |
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Left / Right lung, ___ lobe, wedge biopsy: |
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Left / Right lung, ___ lobe, lobectomy: |
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Left / Right lung, pneumonectomy: |
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Left / Right plura, : |
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Diagnostic Menu -- Wording of Common Abnormalities
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This subsection lists key diagnostic line for the most common diseases in this organ / system. Copy the relevant line(s) by clicking on the button and paste to your report to construct your own report. |
Normal and Nearly Normal:
-- No diagnostic abnormality.
-- Moderate non-specific chronic duodenitis, favor reactive.
-- Focal moderate peptic duodenitis with gastric metaplasia and acute inflammation.
-- Active gluten-sensitive enteropathy (Celiac sprue), Marsh-Oberhuber classification 3b.
Infectious:
-- Intestinal Giadiasis with multiple luminal clusters of trophozites.
-- Severe cytomegalovirus esophagitis with mucosal erosion and granulation tissue.
-- Duodenal infection by mycobacterium avium intracellulare in sheet, confirmed by Ziehl - Neelsen stain.
Neoplastic:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Clinical scenario: .
Right lung, lower lobe, transbronchial biopsy:
-- No diagnostic abnormality, lung parenchyma and bronchial mucosa (see Note).
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, upper lobe, bronchial biopsy:
-- Benign fibromuscular tissue and epithelial cells consistent with bronchial wall.
-- No inflammation or neoplasia is identified in this small biopsy.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, lower lobe, core biopsy:
-- Small fragments of benign bronchial mucosa.
-- Unremarkable ciliated bronchial epithelium, detached.
-- No inflammation or neoplasia is identified.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, lower lobe, bronchial biopsy:
-- No diagnostic abnormality, bronchial mucosa only.
-- No inflammation, dysplasia, fibrosis or neoplasia.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Lung, right upper lobe, biopsy:
-- Predominantly blood (greater than 75% of the specimen), and benign collapsed lung parenchyma with focal chronic inflammation.
-- No active inflammation, granuloma, glandular dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, upper lobe, core biopsy.
-- Benign bronchial mucosa with adjacent elastic fibrosis and skeletal muscle.
-- No inflammation or carcinoma is identified (see Note).
Note: Specimen is submitted entirely for histologic examination. Multiple additional levels of the tissue blocks are examined.
Slides examined: H&E x 3
CPT code: 88305 x 1
Nonspecific changes (inflammation, fibrosis etc.)
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Clinical scenario: .
Right lung, middle lobe, transbronchial biopsy:
-- Inflamed necrotic debris and reactive type-2 pneumocytes.
-- No carcinoma is identified in this biopsy (see Note).
Slides examined: H&E x 3
CPT code: 88305 x 1
Right lung base mass, biopsy:
-- Benign lung parenchyma with focal minimal reactive interstitial fibrosis.
-- No malignancy (see Note).
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, upper lobe, core biopsy:
-- Focal moderate chronic inflammation and associated interstitial fibrosis, reactive.
-- No granuloma, dysplasia or carcinoma is identified in this biopsy.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, upper lobe, apical segment, transbronchial biopsy:
-- Focal highly atypical epithelial cells, cannot be further characterized (see Note).
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, lower lobe nodule, core biopsy:
-- Focal moderate chronic inflammation (see Note).
-- No dysplasia or carcinoma is identified in this biopsy.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Left lung, lower lobe, wedge biopsy:
-- Diffuse mild interstitial lung fibrosis with alveolar foamy microphages, consistent with a nonspecific reactive/inflammatory process (see Note).
-- Rare multinucleated giant cells associated with lymphoid aggregates.
-- No malignancy is identified.
-- No acute inflammation, abscess or granuloma is identified.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, upper lobe, core biopsy:
-- Hypocellular hyalinized fibrosis with peripheral chronic inflammation, at least 6 mm measured on slides, present in all biopsy cores.
-- No epithelial dysplasia or carcinoma.
-- No fungal organisms are identified on GMS special stain.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Left lung, upper lobe, biopsy:
-- Focal acute and chronic inflammation, fibrosis, hemosiderin-laden macrophages and alveolar smoke macrophages:
-- No epithelial dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Left lung, lower lobe, endobronchial biopsy:
-- Reactive desmoplastic fibrosis (see Note).
-- Unremarkable cartilage and ciliated bronchoepithelial cells.
-- No active inflammation, granuloma, epithelial dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Right lung, wedge biopsy:
-- Prominent subpleural emphysematous changes and innumerable alveolar smoke macrophages, consistent with a bleb.
-- No pleural rupture, reactive pleuritis, inflammation, interstitial fibrosis or neoplasia.
Slides examined: H&E x 3
CPT code: 88305 x 1
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Clinical scenario: .
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
Granulomatous Inflammation (Infectious & non-infectious)
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Clinical scenario: .
Right lung, lobe, core biopsy:
-- Foamy histiocytic granulomatous change with fibrosis and chronic lymphoplasmacytic inflammation.
-- No necrotizing granuloma, polarizable exogenous material, epithelial dysplasia or carcinoma.
-- No fungal organisms are identified on GMS special stain.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Right lung, upper lobe, biopsy:
-- Necrotizing granulomatous inflammation with prominent fibrosis and lymphoplasmacytic infiltrates, suspicious for infection (see Note).
-- No epithelial dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Left lung, lower lobe, wedge resection:
-- Non-necrotizing granulomatous inflammation with multinucleated giant cells, focal cytoplasmic polarizable crystal material and fibrosis (see Note).
-- Focal possible granulomatous vasculitis.
-- No necrosis, infarction, epithelial dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Left lung, upper lobe, wedge resection:
-- Non-necrotizing granulomatous inflammation with multinucleated giant cells and cytoplasmic polarizable crystal.
-- No vasculitis, necrosis, epithelial dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Right lung, lower lobe, wedge resection:
-- Fibro-necrotizing nodule with extensive central necrosis and fungal forms consistent with histoplasmosis.
-- Destructive arteritis secondary to the fungal infection.
-- No mycobacteria is identified on special stain.
-- No obstructive pneumonia, epithelial dysplasia or carcinoma.
Slides examined: H&E x 6
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Right lung, middle lobe, core biopsy:
-- Prominent non-necrotizing granulomatous inflammation with multinucleated giant cells and focal fibrosis, coalescing into a 1.5 cm nodule.
-- Special stains for fungal organisms and mycobacteria are negative.
-- No polarizable material is identified.
-- No epithelial dysplasia or carcinoma special stain results stain gms.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
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Clinical scenario: .
Left lung, lower lobe, wedge resection:
-- Fibronecrotizing nodule of coccidioidomycosis with extensive central necrosis (xx).
-- No carcinoma or lymphoma is identified.
Slides examined: H&E x 3
CPT code: 88305 x 1; 88312 x 2
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Left lung, upper lobe, lobectomy:
-- Poorly-differentiated invasive adenocarcinoma with prominent spindle cell component
-- No metastatic carcinoma in __ anthracotic lymph nodes (0/___).
-- No obstructive pneumonia.
-- See Tumor Synopsis and Note.
TUMOR SYNOPSIS
Specimen Identification
Specimen, laterality, procedure: Left lung, upper lobe, lobectomy
Lymph nodes submitted and/or identified in the specimen: Yes
Tumor Attributes
Tumor site: Subpleural
Tumor focality: Unifocal
Tumor size: __ cm
Histologic type: Adenocarcinoma (___%) with prominent spindle cell (___%) component
Histologic grade: __
Visceral pleural invasion: Absent
Tumor extension: Confined in the specimen
Lymph-vascular invasion: Suspicious but not diagnostic
Tumor-associated atelectasis or obstructive pneumonitis: Not identified
Treatment effect: Not applicable
Final Margins
Nearest margin: Bronchovascular margin
Distance from specified margin to tumor: At least 3 mm
Bronchial margin: Negative
Vascular margin: Negative
Parenchymal margin: Not applicable
Lymph Nodes
Number of peribronchial nodes (involved/examined): 0/__
Other lymph nodes (involved/examined): 0/__ (see diagnosis section)
Pathologic stage: pT__ N__ M(Not applicable)
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Note: 02958203.
Slides examined: H&E x 8
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
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Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Organ, site, surgical procedure:
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
--
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.