Surgery of Primary Site--Ovary: What code is used to represent this field when a patient has a history of a previous organ removal and has additional surgery/organ removal for a present cancer (e.g., History of a 1984 hysterectomy and in 2003 has ovarian primary treated with BSO)?
For cases diagnosed 1/1/2003 and after: Code the Surgery of Primary Site field to 52 [Bilateral salpingo-oophorectomy WITH hysterectomy].
Surgery of Primary Site--Ovary: How should this field be coded for an ovarian primary when there is a BSO and only the fundus of uterus is removed (not a full hysterectomy)?
Assign surgery code 52 [Bilateral (salpingo-) oophorectomy; WITH hysterectomy]. Code 52 does not exclude a partial hysterectomy.
Surgery of Primary Site--Melanoma: Which surgery codes should be used for cases that have a 1 cm margin? See Discussion.
For a melanoma case the surgery codes in the 30's are to be used when margins are stated to be less than 1 cm. The codes in the 40's are to be used for cases where the margins are greater than 1 cm.
If the margin is exactly 1 cm, assign a surgery code from the 20-36 range. Use a code in the 40's only when the margin is greater than 1 cm.
Surgery of Primary Site--Melanoma: If the surgical margins are greater than 1 cm for length and width but less than 1 cm for depth, do we code surgery in the 30-33 range?
Yes, assign a surgery code from the 30-33 range when any margin is less than 1 cm. Since tumor thickness is an important prognostic factor for cutaneous melanoma, the deep margin is of particular importance.
Surgery of Primary Site--Major salivary gland: How do you code Surgery of Primary Site for a submandibular gland primary when the operative report refers only to an excision of the submandibular "tumor" while the pathology report states the submandibular "gland" was removed? See discussion.
The gross description on the pathology report indicates that the specimen consists of a "submandibular gland." A further description on the pathology report included, "the specimen was sectioned exposing a focally cystic mass that nearly replaces the entire specimen."
For cases diagnosed on 1/1/2003 or after: Code the Surgery of Primary Site field to 40 [Total parotidectomy, NOS; total removal of major salivary gland, NOS], per the pathology report's gross description of the specimen unless the operative report description of procedure indicates that the removal was less than total.
Surgery of Primary Site--Lymphoma/Soft Tissue: How is this field coded for an excision of a neck mass that found lymphoma in soft tissue (C49.0)? See Discussion.
CT scan showed soft tissue mass in the retropharynx. 9/23/2008 Laryngoscopy with biopsy taken of left tonsil and left base of tongue and random biopsies of nasopharynx; FNA of left neck. Path stated left tonsil, squamous papilloma. Left base of tongue, no significant histopathology. Nasopharynx biopsies, compatible with tonsillar tissue. Pretracheal lymph node biopsies, mild reactive lymphoid hyperplasia. 9/30/2008 Excision of left neck mass with limited deep jugular chain lymph node dissection. Path stated lymph node left jugular biopsy, no tumor seen. Soft tissue, left neck biopsy, malignant B cell lymphoma with plasmacytoid differentiation. Addendum from consult: favor a diagnosis of a marginal zone lymphoma. Per the gross description, the specimen was fibrofatty connective tissue in which there is a tumor infiltrate.
Assign code 26 [partial resection]. Use the surgery codes that apply to the primary site. See page C-597 of the 2007 SEER manual for surgery of primary site codes applicable to primary sites of soft tissue coded to C490 - C499.
Surgery of Primary Site--Lung: What code is used to represent "photodynamic therapy" (PDT) for lung primaries? See Discussion.
PDT is not listed in the Surgery to Primary Site field codes for lung.
For cases diagnosed 2003 and later, code the Surgery of Primary Site field to 19 [Local destruction or excision, NOS] for lung primaries. Photodynamic therapy is a surgical procedure that results in the local destruction of tumor.
Surgery of Primary Site--Lung: Is this field coded to 30 [Resection of lobe or lobectomy] or 33 [Lobectomy with mediastinal lymph node dissection] when a lobectomy specimen includes 2 AP window lymph nodes? See Discussion.
LUL lobectomy: 1.7cm apical tumor, DX=mod well diff subpleural SCC, with involvement of pleural surface. 3 peribronchial LN neg and 2 AP window LNs neg. Stage T2N0.
1. No lymph node dissection or sampling was stated to be done
2. The lobectomy specimen contained the LNs
3. Scope of regional LN surgery is coded
Would the surgery to primary site code 30 or 33?
Code surgery of primary site to 30 [Resection of lobe or lobectomy]. According to the information provided, there was no lymph node dissection in this case. The 2 AP window nodes were obtained as part of the lobectomy specimen.
Surgery of Primary Site--Lung: Is a core-out of the main bronchus coded in this field? See Description.
Patient with right lung cancer was not a surgical candidate because of extent of disease. Prior to receiving radiation, patient underwent bronchoscopy, which revealed obstruction from right main bronchial tumor. Core-out of the tumor was undertaken, and a specimen was sent for path evaluation. The physician stated that this was a palliative procedure to relieve obstruction.
Do not code bronchoscopy to clear the airway as surgery of primary site. When combined with laser therapy, cryosurgery, or other tumor destruction, or when combined with excision of tumor, code as surgery of primary site.
For cases diagnosed 1998-2003: Code surgery of primary site for the case described above to 23 [Excision, NOS]. Tissue was excised and sent to pathology.
Surgery of Primary Site--Lung: How is surgery coded when a patient undergoes a mediastinoscopy with mediastinal lymph node sampling and then a later upper lobectomy? See discussion.
The mediastinal nodes were submitted as a separate specimen. The patient also had several peribronchial nodes identified within the lobectomy specimen.
Does code 33 (Lobectomy with mediastinal lymph node dissection) require a complete mediastinal lymph node dissection (i.e. the removal of all lymph nodes in mediastinal chain(s) as opposed to a selective sampling/dissection of lymph nodes from multiple mediastinal chains)?
Assign code 33 in this situation. Code 33 can include mediastinal lymph node sampling.
An official website of the United States government
Home