SEER Inquiry System - Question 20061105 Details

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SEER Inquiry System - Report

Produced: 11/27/2024 11:44 AM

Question 20061105

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Inquiry Details

References:

2004 SEER Manual, 130-131

Question:

CS Extension--Bladder: Can the physician TNM be viewed as a clarifying statement when it provides information not documented elsewhere in medical record as in the example of a pathology report for bladder primary that demonstrates extension into bladder muscle, NOS but the physician documented TNM notes a more definitive T code for depth of muscle invasion? See Discussion.

Discussion:

In the Collaborative Stage manual in general instructions this guideline exists:

"The extent of disease may be described only in terms of T (tumor), N (node), and M (metastasis) characteristics. In such cases, assign the code in the appropriate field that corresponds to the TNM information. If there is a discrepancy between documentation in the medical record and the physician's assignment of TNM, the documentation takes precedence..." (Similar to language to use SEER information over TNM).

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.Yes, you may code CS extension using the physician assigned "T" when it provides information not found elsewhere in the medical record.

Cancer Site Category:

Bladder

Data Item Category:

N/A

Other Category:

N/A

Year:

2006