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| Report | Question ID | Question | Discussion | Answer | Year |
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20031030 | Primary Site--Head & Neck: What is the primary site for a tumor location described as being in the "gingiva between teeth #s 18 and 19? | Code the primary site as C03.1, lower gum. According to the system used by the American Dental Association, tooth #18 and tooth #19 are lower. Teeth #1-16 are upper. Teeth #17-32 are lower. |
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20031018 | EOD-Extension--Head & Neck (Uvula): Is a stage T2 tumor described on the physical exam as an "ulcerated mass occupying uvula midline soft palate, and extending into the right soft palate. It does not extend into the tonsil area nor into the retromolar trigone" coded to 30 [localized, NOS] or 40 [tumor crosses midline]? | For cases diagnosed 1998-2003: Code EOD-extension to 30 [localized, NOS]. This is mucosal spread (since there is no muscle in the uvula). Soft palate and uvula are handled as a single site, and extension from uvula to soft palate is not addressed in EOD. |
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20031129 | Primary Site: How is this field coded for cholangiocarcinoma involving the intrapancreatic bile duct? | Code the primary site as C24.0 [Extrahepatic bile duct, includes Common bile duct] for a cholagiocarcinoma originating in the common bile duct. A portion of the common bile duct is within the head of the pancreas: The intrapancreatic segment of the common bile duct. | 2003 | |
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20031191 | EOD-Clinical Extension--Prostate: How is this field coded when biopsies of the prostatic apex are positive and the physician clinically stages the case as T1c? | For cases diagnosed 1998-2003:
Code clinical extension to 33 [arising in the prostatic apex] when a biopsy of the prostatic apex is positive for malignancy, with no further evidence of involvement. If biopsies of both the apex and another site within the prostate (for example right lobe) are positive and there is no mention that the malignancy arose in the apex, code extension to 34 [extending into the prostatic apex]. |
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20031186 | Immunotherapy/Radiation Therapy: Is I-131 labeled immunoglobulin coded as immunotherapy or radiation therapy? | Code treatment with I-131 labeled immunoglobulin as radiotherapy. The primary action is radiotherapeutic. Radioimmunotherapy (RIT) uses antibodies to deliver the radiotherapy to the site of the tumor. | 2003 | |
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20031063 | Date of Diagnosis: When the clinical information on a scan indicates a history of cancer, how do you code the month and/or year of diagnosis given these terms: "early in year," "late in year," "2-3 months ago," "7 months ago," "new diagnosis." See Description. | Case 1. Diagnosed with CLL in late 1996. Assumptions: Code the term "late" in the year to December. Date of diagnosis would be coded to December 1996.
Case 2. Diagnosed with CLL in early 1997. Assumptions: Code the term "early" in the year to January. Date of diagnosis would be coded to January 1997.
Case 3. Admitted July 2000. Per H & P, patient was diagnosed with prostate cancer 2-3 years ago. Assumptions: Select the higher number in the range (in this case 3 years) and subtract 3 years from date of admit to calculate year of diagnosis. Code diagnosis month to the month patient was admitted. Diagnosis date would be coded July 1997.
Case 4. Admitted in October 2001. H&P states that colon cancer was diagnosed 7 months ago. Assumptions: Subtract 7 months from date of admit. Code date of diagnosis to March 2001.
Case 5. Admitted in December 2001. Per H&P, patient has CLL, presumably a new diagnosis. Assumptions: Assume the H&P statement of "new" to be equivalent to "recent" and code date of diagnosis to date patient was admitted. In this case, date of diagnosis would be coded to December 2001.
Case 6. Admitted for radical prostatectomy for prostate cancer in March 2001. H&P states that his PSA was 5 in November 2000 and in January 2001, PSA was 5.3. Biopsies showed adenocarcinoma. Assumptions: Assume the biopsy was done the same month as the January 2001 increased PSA. Date of diagnosis would be coded to January 2001.
Case 7. Outpatient bone scan done December 2001. Clinical history on the scan stated patient has history of prostate cancer. The physician was queried about date of diagnosis. Per the physician response, patient was diagnosed in 2001. Assumptions: Assume the bone scan was part of the initial work-up for prostate cancer and estimate the date of diagnosis to December 2001. |
SEER agrees that these are reasonable assumptions based on the information provided.
Estimate the month and year of diagnosis using the available information. If the information is not sufficient to make an estimation on the month, code the month of diagnosis as "99." Avoid coding "unknown" for the year of diagnosis. |
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20031002 | Histology (Pre-2007)--Cervix: Is 8384/3 [adenocarcinoma, endocervical type] a specific histology type that must be stated or does it apply to any adenocarcinoma arising in the endocervical? Should the ICD-O-3 histology code of 8384/3 [Adenocarcinoma, endocervical type] be used for final diagnoses of "adenocarcinoma of the endocervix" or "adenocarcinoma of the cervix"? | For tumors diagnosed prior to 2007:
Histology code 8384 is for adenocarcinoma of endocervical type. This specific type (endocervical) must be part of the diagnosis in order to assign code 8384. This histology code is not to be used for Adenocarcinoma, NOS of the endocervix or cervix. Adenocarcinoma of endocervical type can be diagnosed in other tissues and if so it will be stated as endocervical type. Adenoca of the endocervix would be coded to plain Adenoca.
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules. |
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20031037 | Scope of Regional Lymph Node Surgery 2003+/Number of Regional Lymph Nodes Examined--Hematopoietic/Brain/Lymph Nodes/Ill-defined/Unknown: Are codes 9 [Unknown; not stated] and 99 [Unknown; not stated] used respectively for these data items for the mentioned primary sites? | For cases diagnosed Jan 2003 and later: The Number of Regional Lymph Nodes Examined field is blank for 2003+ cases. Scope of reg lymph node surgery Brain, Central nervous system - 9 Hematopoietic, reticuloendothelial, immunoproliferative & myeloproliferative disease - 9 Unknown & ill-defined primary - 9 Lymphomas - 9 |
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20031035 | Reportability/Histology--Hematopoietic, NOS: Does the presence of sideroblasts on a bone marrow biopsy confirm a diagnosis of refractory anemia with sideroblasts? | Final path diagnosis of bone marrow biopsy:
I. Hypercellular marrow for age with trilinear hyperplasia. II. Decreased iron stores with decreased sideroblasts.
Comment: Although the overall picture is not diagnostic of a specific entity, it is most consistent with an early stage myelodysplastic syndrome which would best be considered refractory anemia at this point.
In this case the percentage of sideroblasts is not stated. Would the path diagnosis of "decreased sideroblasts" along with the path comment of "refractory anemia" indicate that this case should be coded to 9982/3 [Refractory anemia with sideroblasts]? |
For cases diagnosed prior to 1/1/2010:
For the hematologic diseases, do not accession the case unless there is a definite positive diagnosis. A positive diagnosis, such as "Refractory anemia" must be stated in order to code that diagnosis. Other words associated with the positive diagnosis, such as "sideroblasts" are NOT to be used alone to assume a diagnosis.
Decreased sideroblasts does not make a diagnosis of Refractory anemia with sideroblasts. The sideroblasts for 9982/3 [Refractory anemia with sideroblasts] are characteristic in rings, and are INCREASED to make the diagnosis.
Based on the information provided, this case is not reportable. The final path diagnosis is not a reportable disease. The comment further states that the overall picture is not diagnostic of a specific entity. Therefore, it should not be reported at this point.
For cases diagnosed 2010 forward, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ. |
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20031077 | Histology (Pre-2007)--Lung: What code is used to represent the histology "mucin-producing bronchoalveolar carcinoma?" Is mucin-producing synonymous with mucinous? | For tumors diagnosed prior to 2007:
Code histology as 8253 [Bronchiolo-alveolar carcinoma, mucinous]. Mucin-producing bronchoalveolar carcinoma is best classified in ICD-O-3 as Bronchiolo-alveolar carcinoma, mucinous.
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules. |
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