Reportability/Behavior--Brain and CNS: How is a brain "neoplasm" diagnosed only by CT scan reported to SEER? See Discussion.
We have a significant number of patients who come into our emergency room and are diagnosed with a brain neoplasm by CT scan. They are transferred to another facility for further care. Some of those facilities will give us information - histology, treatment, etc. Some will not. How are we supposed to report these brain neoplasms if we don't know if they are benign or malignant? Can we report them as behavior code 9 or do we just report them as benign if we can't get any further information?
The case above is reportable and 8000/1 is the most appropriate histology/behavior code. A clinical diagnosis alone from diagnostic imaging reporting a brain 'neoplasm' (with a diagnosis date supporting the reportable case requirements) even with no other information available (from biopsy or resection) is reportable. Care should be taken when reviewing terms used by the radiologist on these reports, since some tumors exhibit defining characteristics that can be picked up on diagnostic imaging.
Date of diagnosis/Flag: Will the Date of Diagnosis Flag ever be used if the instructions for coding Date of Diagnosis are followed? See Discussion.
If an abstractor follows the instructions for coding the Date of Diagnosis and can at least estimate a year of diagnosis, in what scenario will the Flag be used?
Per the 2010 SEER Manual,
Page 49 Date of Diagnosis, second paragraph, "Regardless of the format, at least Year of diagnosis must be known or estimated. Year of diagnosis cannot be blank or unknown." The manual gives the following guidelines for coding diagnosis date/flag:
Page 50, Coding Instructions:
3. If no information about the date of diagnosis is available
a. Use the date of admission as the date of diagnosis
b. In the absence of an admission date, code the date of first treatment as the date of diagnosis.
Page 51, Coding Instructions:
9. Estimate the date of diagnosis if an exact date is not available. Use all information available to calculate the month and year of diagnosis.
Page 53, Date of Diagnosis Flag, Coding Instructions:
Always leave blank. Date of Diagnosis will always be a full or partial date recorded.
The date of diagnosis flag should always be blank.
Date of Diagnosis: When a 4/04 clinical impression indicates the appearance of a carcinoma that is contradicted by a negative 4/04 biopsy but is confirmed by a 5/04 resection, should the diagnosis date be coded to April or May? See Discussion.
4/04 colonscopy: irregular fungating mass that has appearance of carcinoma. 4/04 Bx: high grade dysplasia. 5/04: LAR. 5/04 Path: 3.2 X 2.5 cm mass wd adenoca with invasion of muscularis propria.
Should the diagnosis date be 4/04 based on the clinical impression during the colonoscopy OR 5/04 since the path for the bx was negative?
The date of diagnosis for the example above is 05/04 -- the date of the pathology report confirming malignacy. The biopsy in 04/04 negated the 04/04 clinical statement.
Date of diagnosis--Breast: How is the date of diagnosis coded when a mammogram describes only "suspicious calcifications" with a BIRADS category of 4 assigned and the suspicious calcifications are subsequently proven to be malignant on biopsy? See Discussion.
The date of diagnosis is the date when cancer was first diagnosed by a recognized medical practitioner, whether clinically or microscopically confirmed. Ambiguous terminology used to determine reportability is listed in part I of FORDS pages 3-4. No BIRADS categories are included and, therefore, should not be used by the registrar to determine the earliest date of diagnosis. In addition, the term "suspicious for calcification" is not reportable, because calcification is benign condition, unless the physician describes it as malignant. Reference 46637, 12/29/2009 FORDS - In the last paragraph there is a statement that no BIRAD categories are listed...cannot be used to determine earliest date of diagnosis. Does the SEER Program follow this guideline?
The date of diagnosis for this case is the date of the biopsy. There is no reportable diagnosis on the mammogram.
Reportability--Melanoma: Is the following reportable? See Discussion.
PATH: Skin, Lt back exc bx: compound nevus with severe cytoarchitectural atypia and regression. Comment: due to overlap of morphology between MM and nevi with severe atypia, and since there's evidence of regression, consideration for re-excision may be considered if clinically indicated.
The final diagnosis, compound nevus with severe atypia, is not reportable. This diagnosis is not listed in ICD-O-3.
Reportability: Are malignant tumors of genital skin reportable? On page 1 of the 2004 SEER Manual, Reportable Diagnoses, 1.b.i. Exceptions: malignant and invasive histologies not required by SEER - Skin. There is no longer a note that states that lesions ARE reportable for skin of the genital sites. Has SEER discontinued the collection of malignant skin tumors of the genital sites OR is the manual in error?
The histologies listed in the exception on page 1 are NOT reportable when the topography code is C440-C449. The manual specifically lists the topography codes in 1.b.1. Diagnoses with the listed histologies ARE reportable when the topography code is NOT C440-C449. Genital skin sites are not coded C440-C449 so a note is not needed.
Reportability--Brain and CNS: Are spinal schwannomas and neurofibromas reportable or non-reportable?
The most accurate and most current instruction is to report these spinal tumors when they arise within the spinal dura or spinal nerve roots, or when they are stated to be "intradural" or "of the nerve root." Do not report these tumors when they arise in the peripheral nerves. The peripheral nerves are the portion of nerve extending beyond the spinal dura.
Reportability--Brain and CNS: Does a case of astrogliosis meet the criteria for gliomatosis cerebri? See Discussion.
Case clinically stated to be a glioma of the brain. Pathology from resection states astrogliosis.
Anderson's Pathology defines astrogliosis as astrocytic proliferations. Gliomatosis cerebri is defined as diffuse neoplastic transformation of poorly differentiated astrocytes over a wide area; predominantly invovles hemispheric white matter.
The pathologic diagnosis for this case, astrogliosis, is not reportable to SEER. Take the definitive diagnosis for this case from the pathology report from the resection. The pathology report takes precendence over the clinical diagnosis.
Reportability: If a dermatopathologist refers to an atypical fibroxanthoma as a malignant process, but the ICD-O-3 indicates it is a borderline process, is this a reportable case? See Discussion.
"Final Diagnosis: Surface of ulcerated histologically malignant spindle cell neoplasm, consistent with atypical fibroxanthoma. Note: An exhaustive immunohistochemical work-up shows no melanocytic, epithelial or vascular differentiation. Atypical fibroxanthoma is a superficial form of a malignant fibrous histiocytoma."
The pathologist has the final say on behavior. In this case, the pathologist states that this tumor is malignant in the final diagnosis. Therefore, this case is reportable.
Ambiguous Terminology/Date of Conclusive Terminology: If there is an unknown date of diagnosis, should the Ambiguous Terminology field always be coded to 9 and the Date of Conclusive Terminology be coded to 99999999? See Discussion.
Scenario: Mammogram is suspicious for carcinoma, unknown date in 2007. A biopsy prior to admission to reporting facility is positive for carcinoma. Patient seen at reporting facility in June 2007 for treatment.
The purpose of the data item "Ambiguous Terminology" is to flag cases entered into the registry based on a diagnosis with ambiguous terminology. Because the case above was entered into the registry based on conclusive terminology, code Ambiguous Terminology to 0 [Conclusive term] and code Date of Conclusive Terminology to 88888888 [not applicable].
An official website of the United States government
Home