Report | Question ID | Question | Discussion | Answer | Year |
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20031185 | Primary Site: How is this field coded for a mass involving the gastroesophageal junction and lower third of the esophagus? See Description. | We have an EGD report describing an ulcerated and infiltrative circumferential non-bleeding 10 cm. mass of malignant appearance found at the gastro-esophageal junction and lower third of the esophagus. The mass caused a partial obstruction. Biopsies were taken from the the gastroesophageal junction and lower third of esophagus. Pathologic diagnosis: Adenocarcinoma. Would this be coded C26.8? | Search for a statement indicating the site of origin. If the site of origin cannot be determined, and there is evidence of Barrett's esophagus, code the topography in the example above to C15.5 [Lower third of esophagus]. If there is no evidence of Barrett's esophagus, assign code C16.0 [Gastroesophageal junction]. Either C15.5 or C16.0 would be preferable to C26.8, which is very non-specific and includes GI tract, pancreas and biliary tract. | 2003 |
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20031020 | Surgery of Primary Site--Head & Neck: Is the removal of the left tonsil during a bilateral tonsillectomy for a right tonsil primary coded in the surgery of the primary site field to 27 [Excisional bx], 30 [Pharyngectomy, NOS], 31 [Limited/partial pharyngectomy; tonsillectomy; bilateral tonsillectomy], or to code 2 under the Surgical Procedure of Other Site field? See discussion. |
Our notes document a 1/99 SEER e-mail stating that tonsillectomy/tonsillectomy with wide excision would be code to 31. Is this still correct? Some of our coders felt that code 27 or 30 would be more appropriate. Is the removal of the contralateral tonsil incidental removal or do we code it under Surgery of Other Regional Site, Distant Site, or Distant Lymph Nodes? If it is coded, would 5 be the correct code? |
Assign code 31 [Limited/partial pharyngectomy; tonsillectomy, bilateral tonsillectomy]. Do not code removal of the contralateral tonsil under Surgical Procedure of Other Site. Surgery to remove regional tissue with the primary site during the same procedure is coded in the Surgery of Primary Site field. |
2003 |
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20031032 | Diagnostic Confirmation--Hematopoietic, NOS: How should diagnostic confirmation of Hematopoietic diseases be coded in the absence of positive bone marrow? See Description. | Case 1. Patient admitted 9-12-02 with diagnosis of essential thrombocythemia. Per the H&P, patient obviously has had this since January 2001. Per the clinical history: patient with elevated platelets. Path diagnosis of bone marrow biopsy done 9-20-02 showed mildly increased megakaryocytes. 10-31-02 clinical sign-out diagnosis was: essential thrombocythemia. Case 2. Patient admitted for evaluation of erythrocytosis. Assessment: Increased hematocrit only. It is most likely that patient has polycythemia vera. I think it is reasonable to initiate phlebotomy treatment. |
Code 1, Positive histology, includes diagnostic hematologic findings and peripheral blood smears when these are the basis for diagnosis. When the clinician makes a specific diagnosis and the blood work is not diagnostic, code diagnostic confirmation as 8 [Clinical diagnosis only]. The clinician is putting together all evidence, including the blood work and using his/her professional experience to diagnose the case. Case 1. The diagnosis is not based on microscopic findings. Assign code 8 [Clinical diagnosis only]. Megakaryocytes are the immature form of thrombocytes, but mildly increased megakaryocytes are not diagnostic of essential thrombocythemia. Case 2. The diagnosis is not based on microscopic findings. Assign code 8 [Clinical diagnosis only]. |
2003 |
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20031025 | Histology (Pre-2007): Is a small cell undifferentiated carcinoma coded to 8041/34 [small cell carcinoma undifferentiated] or to 8045/34 [combination small cell AND undifferentiated carcinoma] using terms from the 2 columns in Appendix 1 of Coding Complex Morphologic Diagnoses? See discussion. | Per pathology report, diagnosis is small cell undifferentiated carcinoma in biopsies taken from the laryngeal surface of the epiglottis and left false vocal cord. | For tumors diagnosed prior to 2007:
Code histology as 8041/34 [small cell carcinoma, undifferentiated]. The diagnosis indicates that this is an undifferentiated small cell carcinoma, rather than a mixture of small cell carcinoma with undifferentiated carcinoma.
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. |
2003 |
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20031085 | Primary Site/Histology (Pre-2007): What are the correct site and histology codes for "tubal serous adenocarcinoma" identified in a fallopian tube? See Description. | The pathology report of a laparoscopic left salpingo-oophorectomy states: 1.5 cm intraluminal mass left fallopian tube: micro: tubal serous adenocarcinoma, poorly differentiated, infiltrates the muscular wall of the fallopian tube; serosa does not appear to be penetrated. The left ovary is negative for malignancy. | For tumors diagnosed prior to 2007:
Code histology as 8441 [serous adenocarcinoma]. The primary site for this case is fallopian tube, not the suggested site code of ovary.
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. |
2003 |
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20031005 | Histology (Pre-2007): Do the terms "keratinizing" or "non-keratinizing" have to be present in the final diagnosis to use codes 8071 through 8073? See discussion. | Should "squamous cell carcinoma, small cell variant" be coded to 8073 even though the final diagnoses does not include the phrase "non-keratinizing?" | For tumors diagnosed prior to 2007:
It is acceptable to assign code 8073/3 for squamous cell carcinoma, small cell, NOS. Code squamous cell carcinoma, large cell, NOS to 8072/3. Code to non-keratinizing unless the pathology report specifies keratinizing.
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. |
2003 |
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20031131 | Multiple Primaries (Pre-2007): Would osteosarcoma of the right arm diagnosed four years after malignant fibrous histiocytoma, also in the right arm, be a second primary when the physician states, "the patient's disease progressed to sarcoma after radiation was administered?" |
For tumors diagnosed prior to 2007: The osteosarcoma is a second primary. The first three digits of the histology codes are different: 8830 [Malignant fibrous histiocytoma] and 918_ or 919_ [Osteosarcoma]. In addition, the diagnoses are four years apart. According to SEER rules, these are separate primaries. 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. |
2003 | |
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20031056 | Multiple Primaries (Pre-2007)--Breast: For a patient with a remote history of lobular breast carcinoma, would a new diagnosis of lobular breast carcinoma with DCIS be a new primary, even though the physician designates it as recurrent? See Description. |
A history of right breast lobular ca in 1991 treated with a partial mastectomy. Diagnosed 3/02 with "recurrent right breast ca" per physician; pathology in 2002 is lobular and DCIS. Would the DCIS make this a new primary regardless of the physician's designation of 'recurrent' or is this the same primary? |
For tumors diagnosed prior to 2007: Accession as two breast primaries -- the first lobular ca in 1991; the second lobular and DCIS in 2002. The differing histologies and the length of time between them negate the physician's designation as "recurrent" in this case. 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. |
2003 |
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20031015 | EOD-Extension--Lymphoma: How is the following guideline of "any mention of lymph nodes is considered indicative of involvement" applied for EOD-Extension of lymphoma cases when there is a discrepancy between physicians as to the stage at diagnosis? See discussion. | A biopsy of mesenteric nodes confirmed lymphoma. A bone marrow biopsy was negative. A CT of the chest indicates "small mediastinal and bilateral hilar nodes, but without convincing adenopathy." The case was Stage 2 per the oncologist and Stage 3 per the surgeon's TNM form. | For tumors diagnosed 1998-2003:
Based on the information provided for this example, the lymphoma involves one site, mesenteric nodes. Code EOD extension as 10 [Involvement of a single lymph node region]. The statement "For lymphomas, any mention of lymph nodes is indicative of involvement" refers to the terms in the paragraph above it on page 8 of the EOD manual: Palpable, enlarged, visible swelling, shotty, lymphadenopathy. While these terms are ignored for other malignancies, they should not be ignored for lymphomas. None of these terms apply to the example provided here. According to the CT, the mediastinal and hilar nodes are "small" "without convincing adenopathy." In other words, the mediastinal and hilar nodes are negative. |
2003 |
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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. |
2003 |