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Produced: 11/25/2024 3:28 PM
Question 20051072
Inquiry Details
References:
#1: CS Manual, Part I, 20. Vers 1.0, Jan. 1, 2004
#2: CS Manual, Part II, 624. Vers 1.0, Jan. 1, 2004
Question:
Discussion:
It was diagnosed on CT-guided biopsy of retroperitoneal mass: obtained access to the posterior aspect of the lesion adjacent to the left side of the spinal column at approx the level of the kidney.
CT Abdomen/Pelvis: Large low attenuation & smooth walled regions in hilum of the spleen & into the splenic parenchyma w/assoc smaller lesions in the spleen. Associated adenopathy on left side of aorta between the superior mesenteric artery & renal vein.
Body of report: Soft tissue mass 4.4 x 4.8 x 7cm adjacent to the left side of the aorta & spanning the distance betw superior mesenteric vein inferiorly to level of left renal vein, appears to be matted adenopathy.
CT Chest: indeterminate nodes in pretracheal region w/calcified nodes in infracarinal region, right perihilar region & calcifications in pulmonary parenchyma of right lung. Calcified nodes & other structures suggest healed granulomatous process. However, with the infarct/mass lesion in the spleen & left periaortic adenopathy, extension of this process to the mediastinum can't be excluded.
Answer:
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.Code the primary site C772 [Intra-abdominal lymph nodes]. Assign CS extension code 22 [Involvement of spleen plus lymph nodes below diaphragm]. The description from the chest CT is not sufficient to code lymph node involvement above the diaphragm.
