EOD-Clinical Extension--Prostate: For prostate cancer, can an elevated PSA be used to code metastasis? See discussion.
5/31/98 PE: 30 gm prostate with nodularity, suspicious for CA.
Final diagnosis: Stage D Ca of prostate with mets, NOS
PTA IVP: Normal collecting system
5/11/98 CXR: NED
PSA 86.3 Suggestive of prostate Ca per MD
5/13/98 TURP and bilat. orchiectomy: Plan was to perform orchiectomy as treatment of choice if biopsy was positive. Appears MD feels that the patient has mets, NOS based on the elevated PSA.
5/13/98 TURP Adenocarcinoma, PD
For cases diagnosed 1998-2003, do not code the EOD-Clinical Extension field based on elevated PSA alone. If a recognized practitioner states that there is metastasis, then metastasis should be coded.
In this case, code the EOD-Clinical Extension field to 85 [Metastasis] because it is Stage D. But if you had D1 or D2 staging based on the involvement of lymph nodes, then that involvement would be coded under EOD lymph nodes and not under the clinical extension field.
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)].
EOD-Extension--Stomach: What code is used to represent this field for a stomach primary described as linitis plastica?
For cases diagnosed 1998-2003:
Code the EOD-Extension field to 30 [Localized, NOS], unless more information is known about the extent of tumor involvement. Coding the Histology field to 8142/3 [Linitis plastica] and the Size of Primary Tumor field to 998 [Diffuse; widespread; 3/4 or more: Linitis plastica] identifies this diagnosis.
In the EOD-Extension field, the depth of invasion is the important characteristic to be coded. The 10 digit EOD corresponds to the AJCC Staging Manual in which the "T" is based on level of invasion. While a diagnosis of linitis plastica indicates a worse prognosis, it does not define the extent of infiltration. There is no luminal mass with linitis plastica. Instead, the entire gastric wall is thickened by tumor.
Surgery of Primary Site/Reconstruction-First Course--Breast: If the plan is to "reconstruct" the breast 6 months after an ipsilateral modified radical mastectomy, is the time span a problem or should it be coded in the Surgery of Primary Site field because it was planned?
For cases diagnosed 1/1/2003 and after: Code the Surgery of Primary Site field to 55 [Modified radical mastectomy WITHOUT removal of uninvolved contralateral breast, Implant]. The time span is not a problem as long as the reconstruction was planned as first course, which is indicated by tissue expander insertion at the time of the original surgery.
EOD-Lymph Nodes--Lung: What code is used to represent this field when the only information is a description of:
1. "hilar mass"
2. "mediastinal mass"
3. "enlarged" or "greater than 1 cm" used to describe any of the lymph nodes listed under code 2 in the EOD Lymph Nodes field?
For cases diagnosed 1998-2003:
Code EOD-Lymph Nodes fields as follows for the examples given:
1) 9 [Unknown; not stated] for a "hilar mass"
2) 2 [Mediastinal] for a "mediastinal mass"
3) 2 [Mediastinal] for "enlarged" or "greater than 1 cm," if used to describe any of the named lymph nodes listed under code 2 in the EOD-Lymph Nodes field.
EOD-Extension--Mycosis Fungoides: Explain the difference between extension codes 25 [% of body surface not stated, no tumors] and 30 [skin involvement, NOS; extent not stated, no tumors. Localized, NOS]?
For cases diagnosed 1998-2003:
For mycosis fungoides: Use code 25 when skin involvement is present but only a general location/site is mentioned (i.e., face, legs, torso, arms).
Use code 30 when there is skin involvement but there is no mention of location/site.
EOD-Extension--Lung: Should the phrase "some pleural fluid in both posterior gutters" be interpreted as pleural effusion for lung primaries? See discussion.
CT scan: "3 cm mass left upper lobe of lung. Some pleural fluid in both posterior gutters. Large matted hilar lymph nodes, left. Some narrowing left upper bronchus by this adenopathy. Squamous cell ca lung with mets to left hilar lymph nodes, most likely possibility." Would you code extension to 72 [malignant pleural effusion; pleural effusion, NOS]?
For cases diagnosed 1998-2003:
Yes. Code the EOD-Extension field to 72 [malignant pleural effusion, pleural effusion, NOS]. Pleural effusion is mentioned as being present.
EOD-Size of Primary Tumor--Lung: Can tumor size of 002 [Malignant cells present in bronchopulmonary secretions] be used when there is a lung mass seen but the diagnosis is from a positive bronchopulmonary secretion?
For cases diagnosed 1998-2003:
EOD-Size of Primary Tumor code 002 [Malignant cells present in bronchopulmonary secretions] is used only when there is no visible primary lung tumor and bronchopulmonary secretions are positive for lung malignancy.
Even if the diagnosis was made by cytology of broncho-pulmonary secretions, if there is a visible mass, code the size of the mass if known, code 999 if size is unknown.
Radiation: Is "consolidated" radiation therapy coded as part of first course therapy when there is no documentation of "planned treatment" and the radiation is done 4 months after the initiation of treatment?
Yes, "consolidation" treatment is part of a planned treatment regimen. A treatment regimen may consist of the four following phases: