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20150027 | Date of diagnosis--Diagnostic confirmation: How are the diagnosis date and diagnostic confirmation coded when the pathology (needle biopsy followed by resection) reports GIST, NOS and the physician subsequently states this is a malignant GIST and treats the patient for a malignancy? See Discussion. |
Pathologists rarely diagnose a GIST as a malignant tumor. Per the AJCC, GISTs encompass a continuum in terms of biologic potential, with larger more mitotically active tumors landing on the "histologically sarcomatous" or malignant end of the spectrum. Because the pathologists generally do not categorize these tumors as benign or malignant, the judgement is typically made by the clinician in light of all the clinical and pathologic findings. Unless there are obvious distant metastases, the clinician usually decides whether a GIST is malignant and treats the patient as such.
In the case above, the patient underwent a gastric biopsy on 04/10/2014 that showed GIST. The subsequent resection on 04/12/2014 showed a 4.5 cm GIST, spindle cell type with 6 mitoses/5 square mm. The resection pathology report does not indicate the GIST is malignant, but does identify a large tumor with mitotic activity. After reviewing the evidence in this case, the clinician calls this a malignant GIST on 04/29/2014 and starts the patient on Gleevec.
Although neither the biopsy nor the resection call this a malignant tumor, should the date the GIST was first diagnosed (biopsy on 04/10/2014) be used to code the diagnosis date, since this is the date the tumor (ultimately felt to be malignant) was diagnosed? If the diagnosis date is coded as the date malignant GIST was first mentioned (04/29/2014), this would exclude surgery as treatment for this tumor.
Would this be a histologic diagnosis because the tumor was histologically confirmed to be GIST? Or must this be a clinical diagnosis because the diagnosis of malignancy was only made clinically (by the clinician's review of the clinical and pathologic findings)? |
Code the diagnosis date for this case as 04/10/2014. Code the diagnostic confirmation as histologically confirmed. The clinician is using all of the information available to determine the diagnosis, including the biopsy and resection. |
2015 |
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20180109 | Date of diagnosis/Ambiguous terminology--Cervix Uteri: Is the date of diagnosis of a cervical pap smear done in December 2017, that states high-grade squamous intraepithelial lesion with features suspicious for invasion, followed by a cervical biopsy in 2018 positive for squamous cell carcinoma, in 2017? Is the ambiguous term used in the cytology in 2017 (suspicious for invasion) to determine diagnosis as the SEER manual states to use the ambiguous cytology as the date of diagnosis if confirmed later. |
Updated for cases diagnosed 2022 or later For cases diagnosed in 2022 or later, see the instructions in the SEER manual under Reportability and Date of Diagnosis for ambiguous cytology. |
2018 | |
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20031100 | Date of diagnosis: Can a positive VMA:HVA test be used as a date of diagnosis for neuroblastoma? See Description. |
Rubin's Clinical Oncology states: Both the catecholamines and their metabolites are used as markers for neuroblastoma, with vanillylmandelic acid (VMA) and homovanillic acid (HVA) being the most commonly used. While their absolute values are not of prognostic significance, a higher VMA:HVA ratio suggests a better prognosis for patients with disseminated disease. |
Updated answer July 2024 No. Do not code the neuroblastoma diagnosis date from only the date of an elevated urine catecholamine test (VMA or HVA). Neuroblastoma diagnosis should be made on the basis of tissue biopsy or bone marrow aspiration along with elevated urinary catecholamines. Elevated urinary catecholamines alone are not diagnostic of neuroblastoma. |
2003 |
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20031052 | Diagnostic Confirmation--Hematopoietic, NOS: Is a multiple myeloma diagnosed by an FNA of the lumbar spine (or any other non-bone marrow location) a diagnostic confirmation 1 or 2? See Description. |
Does the rule on page 111 of the SEER Program Coding Manual, 3rd Edition, for code 1 apply to myelomas (in the same way it applies to leukemias)? |
Assign code 1 [Positive histology] for aspiration of bone marrow. This rule is not limited to leukemias. |
2003 |
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20210044 | Diagnostic Confirmation--Heme & Lymphoid Neoplasms--Plasma Cell Myeloma: Can serum protein electrophoresis (SPEP) be used as a definitive diagnostic method in the absence of a bone marrow biopsy? Is it appropriate to assign code 5 (Positive laboratory test/marker study) if there is no histological confirmation? See Discussion. |
Patient was diagnosed with lambda myeloma based on the M spike found on serum protein electrophoresis. A bone marrow biopsy was performed, but it was an insufficient sample. SPEP is not listed in the Hematopoietic Database as a lab test that can be used as a definitive diagnostic method. Since the physician did base the diagnosis on the SPEP result, would it be appropriate to assign code 5 (Positive laboratory test/marker study) since there was no histological confirmation? Under code 5, the Hematopoietic Manual states: Laboratory tests are listed under Definitive Diagnostic Methods in the Hematopoietic Database. |
Assign code 5 in Diagnostic Confirmation. We consulted with an expert hematopathologist who stated that SPEP would qualify for a diagnostic confirmation code of 5. He also stated that normally a SPEP is followed by a bone marrow biopsy. SPEP has been added to the Definitive Diagnostic Methods for plasma cell myeloma (9732/3). |
2021 |
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20250008 | Diagnostic Confirmation--Heme & Lymphoid Neoplasms: How is Diagnostic Confirmation coded for hematopoietic and lymphoid neoplasms (heme) when immunophenotyping, genetics, etc. confirm the diagnosis. |
Assign Code 3 (Positive histology PLUS positive immunophenotyping or genetic testing) for 1. Cases with positive histology for the neoplasm being abstracted (including acceptable ambiguous terminology and provisional diagnosis), AND
2. A not otherwise specified (NOS) histology diagnosed and not a provisional diagnosis, AND genetic/immunophenotyping was performed and positive Refer to the current version of the Heme Manual for specific notes and examples when coding Diagnostic Confirmation. |
2025 | |
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20190043 | Diagnostic Confirmation: How is Diagnostic Confirmation coded for malignancies diagnosed by a FoundationOne Liquid biopsy/assay involving circulating tumor DNA in blood only? See Discussion. |
Example: FoundationAct assay of circulating tumor DNA in blood sample results: Tumor type = non-small cell lung carcinoma, NOS, with 3 genomic alterations identified: NRAS Q61H, IDH2 R140Q and TP53 V172F. The tumor was identified on imaging and the imaging findings were not clearly what one would expect to see with a SCLC. |
Code Diagnostic Confirmation as 7, Radiology and other imaging techniques without microscopic confirmation for this case. Results of a FoundationOne Liquid biopsy/assay are not specific enough to diagnose this lung malignancy. |
2019 |
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20170006 | Diagnostic confirmation--Heme & Lymphoid Neoplasms (Lymphoma): To code "3" in Diagnostic Confirmation, does the genetic testing need to confirm a specific histology or is it enough that is simply rules out others? See Discussion. |
For example, pathology states: Right axillary lymph node, excision: Diffuse large B-cell lymphoma (DLBCL) (see note). COMMENT: FISH studies were performed that were negative for BCL-6, c-Myc/IgH, CCND1/IgH and IgH/BCl-2 gene rearrangement, ruling out the most common forms of double-hit lymphoma. Flow cytometry studies demonstrated positivity for CD45, CD20, HLA-Dr, CD19, CD11c, CD22, CD30, CD38, CD79b, and FMC7. Low positivity was seen for CD5. No reactivity was seen for CD10, CD23, CD25, CD103 or CD123. |
Both histologic plus immunophenotyping or genetic testing should be positive to assign code 3 for Diagnostic Confirmation. The Hematopoietic and Lymphoid Neoplasm Coding Manual Diagnostic Confirmation instructions state, assign 3 for Cases positive for neoplasm being abstracted (including acceptable ambiguous terminology and provisional diagnosis) AND Immunophenotyping, genetic testing, or JAK2 is listed in the Definitive Diagnosis in the Heme DB AND a.) Confirms the neoplasm OR b.) Identifies a more specific histology (not preceded by ambiguous terminology). Because the patient was diagnosed with DLBCL by histology, and flow cytometry was positive for CD antigens (immunophenotyping) 20, 22, and 30 for DLBCL, code 3 is appropriate. |
2017 |
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20130155 | Diagnostic confirmation--Heme & Lymphoid Neoplasms: How do we code diagnostic confirmation if the pathology report states the diagnosis of a skin biopsy is "low-grade B cell lymphoma, most compatible with marginal zone lymphoma," genetic data includes positive rearrangement for immunoglobulin heavy chain gene favor a diagnosis of "B cell lymphoma," and the physician's clinical diagnosis is "cutaneous marginal zone lymphoma"? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
Code diagnostic confirmation to 3 [positive histology AND positive immunophenotyping studies (9590/3 - 9992/3)].
Immunoglobulin heavy and light chain genes rearranged is listed under Genetics Data in the Heme DB for 9699/3 [extranodal marginal zone lymphoma]. Given the documentation of this positive genetic finding and the positive bone marrow, code diagnostic confirmation to 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. |
2013 | |
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20120015 | Diagnostic confirmation--Heme & Lymphoid Neoplasms: How does one determine and code a clinical diagnosis for the diagnostic confirmation in patient diagnosed with essential thrombocythemia? See Discussion. |
The Heme DB originally stated the Definitive Diagnostic Method is coded to 8 [clinical diagnosis only] while an updated version stated it can coded as a clinical diagnosis or it can be based on the results of a bone marrow biopsy or a genetic test. The Abstractor Note section specifies this is a diagnosis of exclusion. According to a recent Web-based training seminar, the JAK-2 diagnosis would be coded 5 [positive laboratory test/marker study]. Doesn't the Definitive Diagnostic Method of a clinical diagnosis/diagnosis of exclusion mean that the diagnostic confirmation of essential thrombocythemia will always be coded as 8 [clinical diagnosis only]? Many people use code 3 for positive bone marrow biopsy and genetics (JAK-2), but the bone marrow is usually reported as only borderline or is stated to be abnormal for a person's age.
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For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
Code the diagnostic confirmation to 8 [clinical diagnosis only] in this case.
Per the Heme DB, JAK-2 is only positive in about 50% of essential thrombocythemia (ET) patients. In addition, a positive JAK-2 test does not identify the type of myeloproliferative disease (MPN) the patient has, only the presence or absence of the JAK-2 mutation.
The WHO guidelines for diagnosing ET are: elevated platelet count over months and the elimination of other causes for an elevated platelet count (such as polycythemia vera (PV), chronic myelogenous leukemia (CML), idiopathic myelofibrosis, or myelodysplastic syndrome (MDS)); the absence of Philadelphia chromosome, BCR/ABL fusion gene; and del(5q), t(3;3)(q21;26),inv(3)(q21q26)).
Subsequently, the physician rules out any underlying causes of thrombocytosis such as an inflammation or infection, other neoplasms, and prior splenectomy.
Ultimately, there is a diagnosis of exclusion. In other words, all other causes for the elevated platelet count have been excluded. The physician assembles the information from the blood counts, bone marrow and JAK-2 testing along with the information that excludes all other diseases and makes a clinical diagnosis of ET.
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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