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Requesting provider: CI, MD
Surgical pathology report: Collected: Received: 3/4/2011, the pathologist providing the service is an employee of the lab.
Materials received for consultation: Three referred specimens described as left base of tongue, left tonsil and right tonsil.
Clinical data: Slides are prepared and reviewed in conjunction with the patient being seen for Radiation Oncology consultation for carcinoma of base of tongue
Final diagnosis: Eight slides prepared and reviewed A?H
Left base of tongue (part A) and right tonsil, biopsies (parts B, C, G): Squamous mucosa?? and tonsillar tissue; no carcinoma identified.
Left tonsil, biopsies (parts D, E, F, H): Tonsillar tissue with no carcinoma identified.
What are the CPT®? and ICD-9-CM codes?
CPT: ________
ICD: ________