Sex: How is sex coded for a transsexual diagnosed with a testicular primary? See Discussion.
The Physical Exam states patient is male. There is a note that the patient is transsexual. There is no indication that the orchiectomy was part of gender reassignment surgery.
Code sex to 1 [male]. When the natal sex is known, code that over transsexual.
Spanish Surname or Origin: If Asians, Blacks and Whites with non-Spanish surnames are born in a Spanish country, is this field coded to Spanish or non-Spanish? See discussion.
For example, how do we code Miyako Mitsubishi with race listed as Japanese who was born in Peru or Sylvia Shapiro with race listed as White who was born in Argentina?
For both cases, code the Spanish Surname or Origin field to 0 [Non-Spanish/Non-Hispanic]. Persons with non-Spanish surnames would not be coded as being Spanish solely because they are born in a Spanish country. Do not code Spanish ethnicity based only on birthplace. Place of birth is a separate data item and it can be used in data analysis to identify this particular group of people.
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 - - Esophagus/Stomach/Colon: Is an endoscopic mucosal resection (EMR) for an esophagus, stomach or colon malignancy coded to 20 [local tumor excision, NOS] or to a more specific code such as 22 [local tumor excision combined with electrocautery]?
Assign code 20 [local tumor excision, NOS] for a procedure described as an esophagus stomach or colon endoscopic mucosal resection (EMR), NOS. If there is additional information specifying electrocautery, laser or PDT (for example), assign a more specific code.
Surgery of Primary Site--Bladder: Do we code "random bladder biopsies" as an excisional biopsy (27) or as no cancer directed surgery (00) even if the only involvement mentioned on the pathology reports is "focal carcinoma in situ"?
Code the Surgery of Primary Site field to 00 [None; no surgery of primary site] when only random biopsy procedures are performed on the bladder.
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--Brain and CNS: How is this field to be coded when a patient undergoes stereotactic biopsy of a brain tumor? Path specimen consists of four fragments of tissue measuring .7, .6 and .3 cm.
Assign code 20 [Local excision (biopsy) of lesion or mass. Specimen sent to pathology from surgical event 20].
Surgery of Primary Site--Brain and CNS: How should this field be coded when the procedure is stated to be a "stereotactic CORE biopsy" of a brain tumor? See Discussion.
The most recent version of the Brain Site Specific Surgery schema has a note that states "Assign code 20 [Local excision of tumor, lesion, or mass, excisional biopsy] for stereotactic biopsy of brain tumor." Does this also apply to a stereotactic CORE biopsy?
SINQ 20081118 also states that a stereotactic biopsy should be coded as Surgery of Primary Site code 20.
Assign code 20 [Local excision of tumor, lesion, or mass, excisional biopsy] for a stereotactic core biopsy of brain tumor.
Surgery of Primary Site--Brain and CNS: Is "debulking" of a primary brain tumor coded to 21 [subtotal resection of tumor] or 30 [gross resection of tumor]?
Assign code 21 [subtotal resection of tumor, lesion, or mass]. Debulking removes as much of the tumor volume as possible in cases where it is not possible to remove the entire tumor. Debulking should improve the effectiveness of subsequent radiation therapy and/or chemotherapy.
Surgery of Primary Site--Breast: Does the presence of axillary lymph node(s) in a "simple mastectomy" specimen impact the coding of the Surgery of Primary Site field for breast primaries?
Yes. Determine whether there is, in fact, at least a portion of axillary tissue present. If axillary lymph nodes (not internal mammary nodes) are present in the specimen, code the Surgery of Primary Site field to 51 [Modified Radical Mastectomy WITHOUT removal of uninvolved contralateral breast]. If there are no axillary lymph nodes present in the specimen, code the Surgery to Primary Site field to 41 [Total (simple) mastectomy WITHOUT removal of uninvolved contralateral breast].
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