Surgery Primary Site--Melanoma: How should Surgery of Primary Site be coded for a melanoma diagnosed on punch or shave biopsy followed by a wide excision that shows no residual disease and the gross wide excision specimen size showing no residual is greater than 1 cm in all dimensions (length, width and depth)? See Discussion.
MP/H Rules/Multiple primaries--Penis: How many primaries should be reported for a diagnosis of invasive squamous cell carcinoma (SCC) of the penis in 6/2011, treated with excision and fulguration followed by 10/2014 penile lesion found to be SCC with basaloid features focally highly suspicious for invasion? Clinically, the 2014 tumor is stated to be in situ and recurrent penile cancer and follow-up in 2/2015 indicates there was no evidence of tumor following treatment. Subsequently, in 3/2016 the patient has another penile lesion biopsy showing SCC in situ suspicious for invasion, clinically stated to be recurrent. See Discussion.
Grade--Appendix: What is the code and term to use for the grade/differentiation field for well differentiated, Grade 2 neuroendocrine tumor (NET)? See Discussion.
Surgery of Primary Site--Breast: Would you code a unilateral breast simple mastectomy with tissue expanders and AlloDerm or an acellular dermal matrix as Code 45, Reconstruction with Implant, or Code 46, Reconstruction with Combined Tissue and Implant? See Discussion.
Grade--Prostate: How are the prostate-related fields completed when documentation in pathology reports only includes one of the new grade groups? See Discussion.
Histology--Heme & Lymphoid Neoplasms: How should histology be coded for final bone marrow diagnosis of myelodysplastic syndrome with excess blasts? See Discussion.
MP/H Rules/Histology--Lung: What is the histology code for lung cancer case identified pathologically from a metastatic site that differs from the histology stated by the physician? See Discussion.
MP/H Rules/Histology--Thyroid: How should histology be coded for a thyroidectomy final diagnosis of papillary thyroid carcinoma, favor cribriform-morula variant? See Discussion.