Diagnostic Confirmation: Is it appropriate to code this field to "radiography" confirmation when a CT scan does not actually contain a diagnosis of malignancy, however, the discharge diagnosis in the medical record of "probable malignancy" is likely based on the abnormal CT findings? See discussion.
Histology (Pre-2007)--Colon: What code is used to represent histology when the surgeon describes a sessile polyp and the final path diagnosis is stated as: "Rectal sessile polyp: Invasive moderately differentiated adenocarcinoma" (pathologist does not state that it is "arising in a sessile polyp")?
EOD-Size of Primary Tumor--Breast: For breast cancer cases, is code 002 [Mammography/xerography diagnosis only with no size given (tumor not clinically palpable)] to be used only when there is no work-up beyond a clinical one? See discussion.
EOD-Clinical Extension--Prostate: How do you distinguish between clinical extension codes of 10, 13, 14, and 20 for cases with a benign prostate per digital rectal exam that appear localized after TURP/prostatectomy? Can the clinical extension code of 10 be used if the term "microscopic carcinoma" is noted in the pathology report without also mentioning "foci" or "Stage A" for clinically inapparent tumors?
Surgery of Primary Site/Reconstruction-First Course--Breast: If the plan is to "reconstruct" the breast 6 months after an ipsilateral modified radical mastectomy, is the time span a problem or should it be coded in the Surgery of Primary Site field because it was planned?
Date of Diagnosis--All Sites: Is it better to estimate the month in the date of diagnosis field using the re-excision pathology report date or code the month to unknown if the only available information is the re-excision date? See discussion.
An official website of the United States government
Home