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SEER Inquiry System - Report
Produced: 11/29/2024 12:42 AM
Question 20081088
Inquiry Details
References:
2007 SEER Manual, 135. #2
Question:
Discussion:
In reference to the case below, does it make a difference if the CS T stage is known based on the primary excision but there is no clinical information in the record regarding the nodes or metastasis evaluation.
This scenario is seen on outpatient records of breast biopsies and melanoma excisions; i.e., punch bx followed by gross excision of the lesion but the medical record contains no clinical information or statement of everything else normal.
I&R Question 17625 2/16/2006
A patient was diagnosed with ductal carcinoma in situ by needle core biopsy of the right breast. There was no further information in the chart stating if or where the patient went for staging work-up and treatment. What are the codes for CS Extension, CS Regional Lymph Nodes and CS Distant Mets at Dx?
I&R Answer: Sufficient tissue must be taken to determine the T category. If this is the case, CS Extension = 00.
Unless the physician makes the statement that the physical exam is negative, code the CS Regional Lymph Nodes = 99 CS Distant Mets at DX = 99.
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 CS Lymph Nodes and CS Mets at Dx 00 [None] for an in situ diagnosis with no other information.
The CS instructions state that CS LN's should be coded 00 for in situ because in situ by definition is non-invasive. The same logic applies to CS mets in the case of in situ. The I&R answer will be revised.
