Surgery of Primary Site--Kidney, renal pelvis: How do you code a laparoscopic renal mass core biopsy followed by cryoablation of the tumor? See Discussion.
The note under the local tumor destruction codes states "No specimen sent to pathology from this surgical event 10-15." The patient had a pathologic specimen submitted from his core biopsy, but this was not a tumor excision or excisional biopsy [codes 20, 26-27]. Is the correct surgery code 13 [cryosurgery] because the tumor was only ablated and not excised, or surgery code 23 [any combination of 20 or 26-27 with cryosurgery] because a pathology specimen was submitted?
Code for Surgery of Primary Site to 13 [Cryosurgery]. While the core biopsy provided a pathology specimen, it is not coded as surgery of the primary site.
Surgery of Primary Site--Head & Neck: How is this field coded for a surgery titled "Parotidectomy with facial nerve dissection"? See Description.
If the operative report is not titled "total parotidectomy," can we assume that less than total parotidectomy was done? Can we assume that "facial nerve dissection" and "facial nerve monitoring" are other ways of stating "facial nerve spared"?
Use the best information available to determine whether or not all of the parotid has been removed. It is important to read the entire operative report and review the content of the pathology report. The Op report will usually include wording about how much was removed, and this can be confirmed by the path report. Do not make assumptions about the extent of the surgery based solely on the title used on the operative report.
For cases diagnosed 1998-2003: Code 30 [less than total parotidectomy] can be used when the parotid is not totally removed, but the exact type of partial parotidectomy cannot be determined. "Facial nerve monitoring" and "Facial nerve dissection" are synonymous with "facial nerve sparing."
Surgery of Primary Site--Corpus uteri: How are the surgery fields to be coded when patient undergoes hysterectomy and omentectomy for endometrial primary? See Discussion.
The example for instruction 6 in the 2007 SEER manual on page 179 (for surgery of primary site) states "code an en bloc removal when the patient has a hysterectomy and an omentectomy." There is no Site-Specific Surgery code for corpus uteri that combines hysterectomy with omentectomy. Is the information about removal of the omentum lost or is it documented under Surgical Procedure of Other Site?
Use the most appropriate code in the "Surgery of Primary Site field." Do not code the omentectomy in "Surgical Procedure of Other Site" when it is performed with a hysterectomy for an endometrial primary.
Surgery of Primary Site--Colon: In the absence of detailed operative or pathology report descriptions of the specific segment(s) of the colon removed, should a hemicolectomy be coded if stated by the surgeon to be such?
Yes, code hemicolectomy as stated by the surgeon when there is no conflicting or additional information avaliable.
Surgery of Primary Site--Cervix: How is this field coded for a cervix primary when a biopsy removes the entire tumor? See discussion.
Path from biopsy shows "severe dysplasia--CIN III" and the report from an endocervical curettage (ECC) is "chronic cervicitis"?
For cases diagnosed 1998 and later: Code the Surgery of Primary Site field to 25 [Dilatation and curettage; endocervical curettage (for in situ only)].
Surgery of Primary Site--Breast: Should code 51 (Modified radical mastectomy without removal of uninvolved contralateral breast) be used when a patient has excisional biopsy (22) and axillary dissection followed by a simple mastectomy without removal of uninvolved contralateral breast (41) as part of the first course of treatment?
Assign code 51 or 52 if a patient has an excisional biopsy and axillary dissection followed by a simple mastectomy during the first course of therapy. Code the cumulative result of the surgeries, which is a modified radical mastectomy in this case.
SEER collects only one surgery code per case. Code the most invasive, extensive or definitive surgery in Surgery of Primary Site.
Surgery of Primary Site--Breast: How is this field coded when a re-excision follows a prior mastectomy?
Code the most extensive surgery in Surgery of Primary Site. This is a cumulative field. Assign the appropriate code including all surgeries of the primary site performed during the first course of treatment.
The correct code for mastectomy followed by re-excision will depend on the extent of the re-excision. For example, if the re-excision removed muscle, code radical mastectomy.
Surgery of Primary Site--Breast: How is this field coded when a patient has a reduction mammoplasty (for macromastia) and within the pathology specimen there is an incidental finding of carcinoma?
For cases diagnosed 1998-2003: Code this reduction mammoplasty to 20, 21 or 30, depending on whether or not there was a nipple resection. According to our surgical consultant, a reduction mammoplasty is more like a partial mastectomy than a lumpectomy or other breast surgery.
Surgery of Primary Site--Breast: How is this field coded when a mastectomy and a sentinel lymph node excision, that yields only one lymph node, are performed? See Discussion.
Is there a minimum number of lymph nodes that must be removed in order to code a modified radical mastectomy?
Assign code 41 [Total (simple) mastectomy...] for a simple mastectomy with removal of one or more sentinel lymph nodes. As long as the nodes removed are designated sentinel, use code 41 for a simple mastectomy.
Surgery of Primary Site--Breast: How is this field coded for cryosurgery of the breast?
For cases diagnosed 2003 and later: For cryosurgery alone, without a pathology specimen, assign site-specific surgery code 19 [Local tumor destruction, NOS]. Cryosurgery, cryotherapy or cryoablation uses extreme cold to destroy the tumor cells.
If a specimen is sent to pathology use code 20 [Partial mastectomy, NOS] rather than code 19.
If cryosurgery is followed by further surgery, do not use code 19.
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