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Patient was initially diagnosed with Hodgkin Lymphoma, Nodular Sclerosing on 3/3/06.

Patient received ABVD x 2 cycles. Had disease reassessed in May, 2006, no response to treatment, showed evidence of progression (new adenopathy). Patient's pathology from 3/06 was sent for consult: Diagnosis was Hodgkin with some overlapping features of B-cell Non Hodgkin Lymphoma. Treated 5/18/06 with R-ICE FOR NHL.

Currently, First Course Therapy instruction for expectant management (also referred to as active surveillance, watchful waiting, etc.) instructs one to code 0 or 00 (not done) for all data items when the physician opts for expectant management.

We find that the treatment decisions can be driven by the patient, physician, or combination of both patient and physician depending on the options presented.

Would you code an excisional biopsy as Surgery for the following case?

The patient presented with a large protruding polypoid anal canal mass. The diagnosis of malignancy was made following a procedure referred to by the surgeon as an excisional biopsy. The protruding portion of the anal canal mass was excised, but the deep margin was grossly involved. The PE exam after the "excisional biopsy" found a firm mass, 4 cm in length on DRE. Further work-up with imaging showed gross residual disease extending to adjacent skeletal muscle (external anal sphincter). Although the internal/protruding anal canal portion of the tumor was excised, there was clearly extensive residual tumor. The patient underwent definitive concurrent chemoradiation only; subsequent surgery was not planned or performed.

Unlike most other sites, there is no specific code for a radical surgical procedure of a skin primary. In this case, the patient was diagnosed with a sebaceous cell carcinoma of the lower eyelid skin by punch biopsy. The tumor was large and an orbital exenteration was planned. Despite the extensive surgery performed, skin margins were less than 1 cm. Is an orbital exenteration a "major amputation" (code 60) in this case? Given that the margins were not greater than 1 cm, codes 45 - 47 (which includes a minor (local) amputation) don't seem to apply. However, if this procedure cannot be classified as "minor amputation" then doesn't it seem overkill to refer to the procedure as a "major amputation"?

An alternative would be to code Surgery of Primary Site to 32 for the skin resection (punch biopsy followed by a gross excision of the lesion, margins less than 1 cm) and code Surgical Procedure of Other Site to 2 (non-primary surgical procedure to other regional sites) to record the removal of the globe and orbit as part of the orbital exenteration. Which is correct?

Can you provide clarification on Rectum primary surgical code 40 Pull through WITH sphincter preservation (colo-anal anastomosis)? Would this be code 30 or 40 due to the colorectal anastomosis? 

IMPRESSION/PLAN: Patient is a previously healthy middle aged woman with a diagnosis of adenocarcinoma of the rectum, clinical stage II (T3N0M0). We will proceed with a neoadjuvant course of radiation and concurrent chemotherapy (5-FU) to maximize local regional control and survival, and hopefully facilitate a sphincter-sparing resection in the future. The primary tumor and the pelvic nodes at risk will receive 4500 cGy delivered over 25 treatments. The primary tumor will subsequently receive an additional 1080 cGy delivered over 5 treatments, for a cumulative dose of 580 cGy.

PATHOLOGY: Adenocarcinoma of the rectum, clinical stage II (T3N0M0). The patient is referred by (dr) for a neoadjuvant course of chemoradiotherapy.

HPI: Patient presented recently with rectal bleeding and a change in bowel habits. Colonoscopy revealed an ulcerated mass located 4.0 cm above the anal verge. A biopsy was positive for invasive well-differentiated adenocarcinoma that arose from a tubular adenoma. A staging work-up demonstrated no evidence of metastatic disease.

For C220-C221 primaries, Surgery of Primary Site includes code A150 for Alcohol tumor destruction (percutaneous ethanol injection/intratumoral injection of alcohol/alcohol ablation). The SEER and STORE manuals also indicate that alcohol embolization should be coded as Other Therapy, code 1. We are trying to determine whether alcohol embolization should be coded under Surgery of Primary Site or Other Therapy.