Sugery of Primary Site--Breast: When a patient is simultaneously diagnosed with bilateral breast cancer and bilateral mastectomies are done, do you code the total mastectomies to 40 or 41 or 42?
Abstract cancer of the left breast and cancer of the right breast as separate primaries. Code the surgery for each primary independent of the other primary.
For the first primary, assign code 41 [Total (simple) mastectomy, NOS WITHOUT removal of uninvolved contralateral breast].
For the second primary, assign the code for the procedure performed on that site.
Surgery of Primary Site/Surgery codes, NOS--Colon: What tissue specimens are included under this field's code 41 [Subtotal colectomy/hemicolectomy plus resection of contiguous organ; example: small bowel, bladder]? See Discussion.
How is site specific surgery coded for the following two cases?
Example 1. A right hemicolectomy normally includes a portion of ileum.
Example 2. Subtotal colectomy with bilateral oophorectomy.
Code 40 includes a right hemicolectomy. A right hemicolectomy normally includes a small portion of the terminal ileum removed with the ileocecal valve. Assign code 41 when resection of CONTIGUOUS organs goes beyond what would normally be removed as part of a subtotal colectomy/hemicolectomy. Record non-contiguous organ resection in Surgical Procedure of Other Site.
Example 1: Surgery of Primary Site -- 40 [Subtotal colectomy/hemicolectomy].
Example 2: Surgery of Primary Site -- 40 [Subtotal colectomy/hemicolectomy]. Surgical Procedure of Other Site -- 2 [Non-primary surgical procedure to other regional sites].
Addendum July 2021
For coding Surgical Procedure of Other Site, see the instructions for determining regional vs distant sites in the 2021 SEER manual under Coding Instructions #6 and #7 on pages 184-185. Do not use Summary Stage to determine regional vs distant for this data item.
Surgery of Primary Site--Major salivary gland: How do you code Surgery of Primary Site for a submandibular gland primary when the operative report refers only to an excision of the submandibular "tumor" while the pathology report states the submandibular "gland" was removed? See discussion.
The gross description on the pathology report indicates that the specimen consists of a "submandibular gland." A further description on the pathology report included, "the specimen was sectioned exposing a focally cystic mass that nearly replaces the entire specimen."
For cases diagnosed on 1/1/2003 or after: Code the Surgery of Primary Site field to 40 [Total parotidectomy, NOS; total removal of major salivary gland, NOS], per the pathology report's gross description of the specimen unless the operative report description of procedure indicates that the removal was less than total.
Surgery of Primary Site: Should laparoscopy be coded as exploratory surgery? See discussion.
Many surgeons are doing exploratory surgery with laparoscopy involving a very small incision, but they can examine organs and take biopsies. Should laparoscopy be coded as exploratory surgery?
For cases diagnosed 1/1/1998 and later: Exploratory surgical procedures, such as laparoscopic surgeries, are not coded in the Surgery of Primary Site field.
Surgery of Primary Site--Bladder: Should a TURB be coded to 27 [Excisional biopsy; SEER Note: Code TURB as 27] when there is obvious extravesicular extension demonstrated because the 2004 SEER Manual states "Do not code an excisional biopsy when there is macroscopic residual disease"?
Assign code 27 [excisional biopsy]. The site-specific instructions have priority over the general instructions. According to the instructions for coding surgery of the bladder, use code 27 for TURB.
Surgery of Primary Site--Ovary: What code is used to represent this field when a patient has a history of a previous organ removal and has additional surgery/organ removal for a present cancer (e.g., History of a 1984 hysterectomy and in 2003 has ovarian primary treated with BSO)?
For cases diagnosed 1/1/2003 and after: Code the Surgery of Primary Site field to 52 [Bilateral salpingo-oophorectomy WITH hysterectomy].
Surgery of Primary Site--Skin: What surgery code is used to reflect the amputation of a finger for subungual melanoma?
47 [Wide excision or reexcision of lesion or minor (local) amputation with margins greater than 2cm] is the correct surgery code for amputation of a finger for melanoma.
Surgery of Primary Site--Bladder: Is any mention of cautery in the gross description of pathology for a TURBT specimen sufficient to code 22 (excisional biopsy with electrocautery), or does there need to be a statement in the operative report that electrocautery was performed? See discussion.
Often, pathology for TURBT with non-invasive papillary TCC includes a gross description with a variety of cautery descriptions. For example, "received are three cautery roughened gray-pale pink tissue fragments.” However, the operative report is documented as a "TURBT" with no further description of the procedure.
Assign code 22 when cautery is mentioned n the gross description of pathology for a TURBT specimen.
Surgery of Primary Site--Melanoma: Please further explain the SEER Note under Melanoma surgery codes 30-36 for these two examples. Are both examples coded 31?
1. Shave bx: +melanoma in situ, +microscopic margins Wide excision: no residual melanoma in situ
2. Shave bx: melanoma, +microscopic margin Wide excision: Melanoma, margins negative (margin status negative but distance not stated)
Revised answer: Assign surgery code 30 for both examples based on the SEER Note on the top of page 2 in the Surgery of Primary Site Codes for Skin: If it is stated to be a wide excision or reexcision, but the margins are unknown, code to 30.
An official website of the United States government
Home