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20220033 | When coding the Covid testing results, does SEER have any guidance on whether or not at home tests fall within reportability? For instance, if a medical provider says pt tested positive on an at home test, do we record that? |
When you have information about home COVID tests, record this information. For example, if the home test was positive record as follows: COVID-19 rapid viral antigen test POS 08/09/2022 |
2022 | |
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20220035 |
Solid Tumor Rules/Histology--Bladder: How is histology coded for a transurethral resection of the bladder (TURB) diagnosis with multiple components? See Discussion. |
Examples: Bladder TURB: Invasive high grade urothelial carcinoma with poorly differentiated (40%), lipoid (5%), and sarcomatoid (55%) components. Bladder tumor base TURB: Invasive high grade urothelial carcinoma with poorly differentiated (65%) and sarcomatoid (30%) components. The Urinary Sites Solid Tumor Rules, histology coding rules, say to code the most specific histology or subtype/variant, regardless of whether it is described as majority, minority, or component. Poorly differentiated (8020) and sarcomatoid (8122) are both urothelial subtypes, but there is no rule to instruct how to code a tumor/tumors with multiple urothelial subtypes. |
Code histology as 8120/3 in the two examples using Note 1 in the Urinary Sites Solid Tumor Rules, instruction 1 of the Coding Histology section. The subtypes/variants or components must describe a carcinoma or sarcoma in order to code a histology described by those terms. |
2022 |
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20010118 | All Surgical Fields/Radiation Sequence with Surgery--Unknown Primaries: What codes are used to represent these fields for an unknown primary treated with a radical neck dissection followed by radiation therapy? | For unknown primaries treated with a lymph node dissection and diagnosed 1/1/2003 and after, code: 1) Surgery to Primary Site: 98 [All unknown and ill-defined disease sites, WITH or WITHOUT surgical treatment]. 2) Scope of Regional Lymph Node Surgery: 9 [Unknown or not applicable]. 3) Surgical Procedure of Other Site: 1 [Surgery to other site(s) or node(s), NOS; unknown if regional or distant]. 4) Radiation Sequence with Surgery: 3 [Radiation after surgery]. Any planned surgical treatment is used to code radiation/surgery sequence (per CoC I&R). |
2001 | |
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20061093 | Ambiguous Terminology--Breast: Is a stereotactic biopsy that is "focally suspicious for DCIS" reportable if it is followed by a negative excisional biopsy? See Discussion. | Per the 2004 SEER manual page 4, 1.a, the case is reportable based on the ambiguous term "suspicious" for DCIS. Per the 2004 SEER manual page 4, 1.c, use these terms when screening diagnoses on pathology reports, operative reports, scans, mammograms, and other diagnostic testing other than tumor markers. Note: If the ambiguous diagnosis is proven to be not reportable by biopsy, cytology, or physician's statement, do not accession the case. |
Do not accession this case. The needle localization excisional biopsy was performed to further evaluate the suspicious finding found on stereotactic biopsy. The suspicious diagnosis was proven to be false. | 2006 |
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20110150 | Ambiguous Terminology--Heme & Lymphoid Neoplasms: As ambiguous terminology is not used to code histology for Heme & Lymphoid primaries, how is the histology coded when a patient has a clinical diagnosis of "consistent with a myelodysplastic syndrome"? See Discussion. | The physician states the "patient's clinical picture certainly is most consistent with MDS." Several FISH probes were performed on peripheral blood, specifically looking for the 5q minus syndrome as well as other molecular rearrangements to suggest or confirm MDS. These studies came back as normal. The initial bone marrow also came back negative. The physician then states, "The suspicion was that this represented a myelodysplastic syndrome despite the normal cytogenetics. Additional studies performed on the date of the clinic visit included the FISH for the 5q minus syndrome as well as CD59 to exclude PNH. Both of these were negative. Therefore, at this juncture, the patient has a macrocytic anemia not yet requiring transfusion support with a normal white count and an elevated platelet count and a hypercellular bone marrow. This is certainly consistent with a myelodysplastic syndrome."
Per coding guidelines, ambiguous terminology is not used to code histology, only for reportability. What is the histology code for this case? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
Code the histology as Myelodysplastic syndrome, unclassifiable [9989/3].
Ambiguous terminology is used to accession cases (determine reportability). While ambiguous terminology is generally not used to code a specific histology, it can be used to code histology if it is the .
The statement that you do not use ambiguous terms to code histology is intended for those NOS histologies with an ambiguous term being used to describe the subtype. For example, if the physician states this is a myelodysplastic syndrome, NOS, refractory thrombocytopenia. The correct histology would be MDS, NOS [9989/3] and not refractory thrombocytopenia [9992/3].
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2011 |
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20071072 | 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]. | 2007 |
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20071114 | Ambiguous Terminology/Date of Diagnosis: How would you code the diagnosis date when the body of an imaging report uses reportable ambiguous terminology while the final impression in that same report uses non-reportable ambiguous terminology? Would you code the diagnosis date to the date of the scan or to the subsequent biopsy date that confirmed a malignancy? See Discussion. | Within the body of a mammogram report, the radiologist stated, "diffuse inflammatory tissue throughout the rt breast w/ large rt axillary lymph nodes, consistent with an inflammatory carcinoma of rt breast." His final impression, however, said "extremely suspicious rt breast w/ extremely dense breast parenchyma and adenopathy in axilla, suggesting an inflammatory carcinoma." The patient then went on to have a biopsy, which was indeed positive for cancer. | Accept the reportable ambiguous terminology from the body of the mammogram. Record the date of the mammogram as the date of diagnosis. The guidelines on page 4 of the 2007 SEER manual addressing discrepancies within the medical record can be applied to discrepancies within one report. The instructions are: If one section of the medical record(s) uses a reportable term such as apparently and another section of the medical record(s) uses a term that is not on the reportable list, accept the reportable term and accession the case. |
2007 |
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20031152 | Ambiguous Terminology/Histology (Pre-2007): How do we code histology when there is a difference between the histology mentioned on a suspicious cytology and the clinical diagnosis by the treating physician? See Description. | An FNA of pancreas is stated as "highly atypical cells present, suspicious for pancreatic ductal carcinoma." The attending physician states the patient has pancreatic carcinoma. Can histology be coded 8500/3 [infiltrating duct carcinoma, NOS] or should it be 8010/3 [carcinoma, NOS]? | For tumors diagnosed prior to 2007:
Code the histology from a suspicious cytology when this histology is supported by the clinical diagnosis. Code the example above to 8010/3 [Carcinoma, NOS].
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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20120052 | Ambiguous Terminology/Histology--Heme & Lymphoid Neoplasms: What is the histology code if the final diagnosis is "non-Hodgkin lymphoma NOS," but after further genetic and immunohistochemistry studies were performed the pathology report diagnosis COMMENT section stated the immunohistochemistry findings were "compatible with follicular lymphoma"? See Discussion | Ambiguous terminology is not to be used to code a more specific histology. However the immunohistochemistry results (the definitive diagnostic method for follicular lymphoma) seem to clarify the non-specific diagnosis of non-Hodgkin lymphoma. | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
Ambiguous terms are not used to code a specific histology. This includes ambiguous terminology used as a result of immunophenotyping or genetic studies. However, a definitive clinical diagnosis can be used to code a more specific histology.
In this example, the histology is coded to non-Hodgkin lymphoma, NOS [9591/3] because the pathology final diagnosis was non-Hodgkin lymphoma, NOS even though it was followed by further genetic and immunohistochemistry studies that were "compatible with" (ambiguous terminology) follicular lymphoma.
However, if there was a subsequent non-ambiguous clinical diagnosis, the histology would be coded to the more specific diagnosis. For example, if the pathology final diagnosis was non-Hodgkin lymphoma, NOS, and there was a subsequent clinical diagnosis of follicular lymphoma or the patient was treated for follicular lymphoma, then the histology should be coded to 9690/3 [follicular lymphoma, NOS]. Document either of these in a text field to support the histology code chosen. Follicular lymphoma is a specific type of non-Hodgkin lymphoma. If you do have a confirmed diagnosis of follicular lymphoma, code that specific cell type per rule PH29.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2012 |
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20021015 | Ambiguous Terminology/Reportability: How should the expressions "suspicious for but not diagnostic of" and "suspicious for the possibility of early invasive adenocarcinoma" be interpreted for reportability? Would the interpretation be different depending on the primary site? | For reportability, interpret "suspicious for but not diagnostic of" as NOT diagnostic of cancer.
The phrase "suspicious for the possibility of early invasive adenocarcinoma" may indicate that the case is in situ. If no further information is available, this is not reportable.
The site of the cancer diagnosis does not change the interpretation. |
2002 |
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