Surgery of Primary Site--Head & Neck: Is a composite resection performed for an oral cavity primary coded to 40 [Radical excision of tumor, NOS], 41 [Radical excision of tumor only], 42 [Combination of 41 with resection in continuity with mandibles (marginal, segmental, hemi-, or total resection], 43 [Combination of 41 with resection in continuity with maxilla (partial, subtotal, or total resection)]? See discussion.
Example:
Patient underwent composite resection of left soft palate, tonsillar fossa, medial pterygoid and lateral tongue for a primary of the retromolar trigone. There was no mention of an excision of the mandible; however, the procedure included the application of a mandibular reconstruction plate.
Use surgery codes 40-43 for composite resection of an oral cavity primary. In the case example, code Site-Specific surgery as 42 [Combination of 41 WITH resection in continuity with mandible]. Even though excision of mandible was not mentioned, there was mention of a mandibular reconstruction plate. Since the retromolar trigone is ON the mandible, resection of the mandible is likely.
Date of Diagnosis/Diagnostic Confirmation: How are these fields coded when a physician statement of diagnosis predates a positive biopsy? See Description.
A mass seen on EGD with negative biopsy 12/28/01. Needle core biopsies 1/14/02 were diagnostic of GIST. Gleevec treatment was initiated 2/02, and in discharge summary 5/27/02, the physician says the GIST was diagnosed on EGD.
Code the date of diagnosis as 01/2002. Code the diagnostic confirmation as positive histology. EGD revealed a "mass." Biopsies of the "mass" seen on EGD were negative before January 2002.
CS Extension/Polyp--Colon: How is CS extension coded for tumor invasion described as "Haggitt level 4"? See Description.
Polypectomy specimen revealed adenocarcinoma of the rectum in a tubulovillous adenoma. Per path extent of invasion was Haggitt level 4. The micro description of the tumor stated that there was malignant epithelial neoplasm in colonic mucosa.
In a 1985 Gastroenterology journal article, Haggitt described five levels of polyp invasion:
Level 0-confined to mucosa
Level 1-head
Level 2-Neck
Level 3-Stalk
Level 4-Submucosa of underlying colonic wall.
For cases diagnosed 2004 and forward:
Use the best information available to code CS extension. The following conversion may be used when the only information available is the Haggitt level.
EOD-Pathology Extension--Prostate: Is extracapsular extension implied by the phrase, "involvement of periurethral or urethral margins"? See Description.
The prostatectomy final pathology diagnosis states that the tumor involves the periurethral margin. The microscopic describes involvement of the urethral margin.
For cases diagnosed 1998-2003: Code the EOD-Extension field in the 20-34 range, which implies no extension beyond the prostate. Disregard involvement of periurethral margin or urethral margin, NOS, unless the pathologist or surgeon specifically mentions "extraprostatic urethra" involvement.
First Course Treatment--Thyroid: Is hormone replacement following total thyroidectomy coded as first course treatment for all thyroid cases?
Code Hormone therapy as 01 [Hormone therapy administered as first course therapy] when thyroid replacement therapy is part of the first course of treatment for follicular or papillary thyroid cancer following thyroidectomy.
Thyroid hormone replacement therapy has a treatment effect on differentiated (follicular and papillary) carcinomas of the thyroid. This treatment effect is not seen for most medullary and undifferentiated thyroid cancers.
EOD/Surgery of Primary Site--Melanoma: If a melanoma primary site is other than skin, vulva, penis, or scrotum should these fields be coded using melanoma schemes? See discussion.
Should a melanoma of the cervix be coded using the melanoma or the cervix schemes for these fields?
For cases diagnosed 1998-2003: Use the EOD and surgery code schemes for cervix uteri. The EOD scheme for melanoma excludes melanoma of the cervix uteri. The surgery code scheme for skin excludes cervix uteri.
Reportability--Appendix: Is an appendiceal carcinoid with one periappendiceal lymph node positive for metastatic carcinoid tumor reportable to SEER? See Discussion.
The patient had an appendectomy followed by a hemicolectomy. No residual carcinoid tumor was identified but there was one lymph node positive for metastatic carcinoid tumor.
Yes, this carcinoid is reportable to SEER. This carcinoid is malignant by virture of the lymph node metastasis. Code the behavior as /3.
EOD Extension--Lung: Do we ignore pericardial effusion seen on a CXR if a subsequent lobectomy reveals only a localized tumor? See discussion.
Note 6 in the lung EOD scheme instructs us to assume that a pleural effusion is negative if a resection is done. Does this also apply to a pericardial effusion? For example, if a pericardial effusion is seen on CXR, and a subsequent lobectomy reveals only a localized tumor, should the effusion be ignored?
For cases diagnosed 1998-2003: Ignore pericardial effusion which is negative for tumor. Assume that a pericardial effusion is negative if a resection is done and the tumor is pathologically confirmed to be localized.
Diagnostic Confirmation--Hematopoietic, NOS: How should diagnostic confirmation of Hematopoietic diseases be coded in the absence of positive bone marrow? See Description.
Case 1. Patient admitted 9-12-02 with diagnosis of essential thrombocythemia. Per the H&P, patient obviously has had this since January 2001. Per the clinical history: patient with elevated platelets. Path diagnosis of bone marrow biopsy done 9-20-02 showed mildly increased megakaryocytes. 10-31-02 clinical sign-out diagnosis was: essential thrombocythemia.
Case 2. Patient admitted for evaluation of erythrocytosis. Assessment: Increased hematocrit only. It is most likely that patient has polycythemia vera. I think it is reasonable to initiate phlebotomy treatment.
Code 1, Positive histology, includes diagnostic hematologic findings and peripheral blood smears when these are the basis for diagnosis.
When the clinician makes a specific diagnosis and the blood work is not diagnostic, code diagnostic confirmation as 8 [Clinical diagnosis only]. The clinician is putting together all evidence, including the blood work and using his/her professional experience to diagnose the case.
Case 1. The diagnosis is not based on microscopic findings. Assign code 8 [Clinical diagnosis only]. Megakaryocytes are the immature form of thrombocytes, but mildly increased megakaryocytes are not diagnostic of essential thrombocythemia.
Case 2. The diagnosis is not based on microscopic findings. Assign code 8 [Clinical diagnosis only].
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