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SEER Inquiry System - Report
Produced: 11/29/2024 4:56 PM
Question 20110009
Inquiry Details
References:
#1: Heme & Lymph Manual & DB
#2: Diagnostic Confirmation Coding Instructions
Question:
Discussion:
2/11/10 bone marrow biopsy revealed "mild trilineal dysplastic changes in conjunction with chronicity of cytopenias is worrisome for MDS." Cytogenetics are positive for 5q deletion. Clinicopathologic correlation required for final diagnosis. On 2/25/10 the physician confirms a diagnosis of refractory cytopenia with multilineage dysplasia.
Is the date of diagnosis 2/11/10 with diagnostic confirmation of 3 or 2/25/10 with diagnostic confirmation of 8?
Answer:
The date of diagnosis is 2/25/10 and diagnostic confirmation is coded to 8 [clinical diagnosis only].
As the cytogenetics state, you need clinicopathologic correlation to get confirm a reportable diagnosis. There is no reportable diagnosis from the bone marrow biopsy. The cytogenetics were done (the pathologic part) and then the physician confirmed refractory cytopenia with multilineage dysplasia [9985/3] (the clinical part). The diagnostic process and the determination of a reportable diagnosis were completed when the clinician made the statement that this is refractory cytopenia with multilineage dysplasia.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.
