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SEER Inquiry System - Report
Produced: 11/28/2024 5:58 AM
Question 20091012
Inquiry Details
References:
2007 SEER Manual, 81
Question:
MP/H Rules/Histology--Head & Neck: If the final diagnosis states "see microscopic description," can the micro information be used to code the histology? See Discussion.
Discussion:
In regards to coding histology for 2007 and forward cases, we are instructed to use the final diagnosis, and any addenda or comments associated with the final diagnosis. We are not to use the microscopic description. However, we are seeing pathology reports with a final diagnosis that also includes the notation "see microscopic description" or "see description". Example: "Left Parotid: High grade carcinoma involving deep lobe with marginal extension. See description." The microscopic description goes on to describe the carcinoma in more detail, which includes a statement "consistent with the ductal type of primary parotid carcinoma." Can we use this microscopic description or not?
Answer:
For cases diagnosed 2007 or later:
When the final diagnosis indicates that the microscopic section contains the detailed diagnosis, use the microscopic description to code the histology.
Otherwise, code from the final diagnosis only and not from the microscopic description. The final diagnosis is usually the pathologist's conclusion after consideration of the various choices listed in the microscopic description. The histology code should represent the pathologist's final conclusion.
Cancer Site Category:
N/A
Data Item Category:
Histology
Other Category:
N/A
Year:
2009
