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SEER Inquiry System - Report
Produced: 08/05/2024 4:09 PM
Question 20081039
Inquiry Details
References:
2007 SEER Manual, 76, 83
Question:
Discussion:
Frequently, pathology reports describe hematopoietic diseases using ambiguous terms. Flow cytology and cytogenetics may be obtained. It appears that the clinician is the person who pulls all the information together for a diagnosis.
Example: Bone marrow biopsy is most compatible with chronic phase myeloproliferative disease. Path comment: Differential would include CML. Outside hematology report indicates an elevated peripheral WBC, primarily neutrophils. Flow cytometry showed 1.0 % of the white cells are myeloid blasts of abnormal phenotype, additionally finding 7.3 % basophils. Flow reported peripheral blasts at 1.2 % and peripheral basophilia. Cytogenetics report showed abnormality with trisomy of chromosomes 13 and 21. This finding is consistent with a clonal abnormality suggestive of acquired disease. Results were consistent with the absence of the t(9,22)(q34;q11) translocation or fusion product associated with CML. Subsequent clinical impression: Bone marrow evaluation most consistent with CML. Overall features most consistent with CML.
Answer:
For cases diagnosed prior to 1/1/2010:Code the Diagnostic Confirmation field as 1 [positive histology]. Code the ICD-O-3 morphology based on the clinician's statement.
The code in Diagnostic Confirmation pertains to the best method used to confirm the presence of cancer over the entire course of the disease. Therefore, if a bone marrow report confirms cancer, code 1 [positive histology] in Diagnostic Confirmation.
Code the histology using all of the information available. The clinician has access to all of the information relating to this case. The pathologist had only the bone marrow. Code the histology recorded by the clinician.
For cases diagnosed 1/1/10 and later, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
