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.
MP/H Rules/Histology--Colon: What histology would be coded when the right colon demonstrates a combined adenocarcinoma and high grade small cell neuroendocrine carcinoma [forming the dominant component] arising in a villotubular adenoma and the liver biopsy demonstrates metastatic high grade small cell neuroendocrine carcinoma?
For cases diagnosed 2007 or later, start with rule H1 in the Single Tumor module. Stop at rule H4. Assign code 8263 [adenocarcinoma in tubulovillous adenoma].
Stop at the first rule that applies. Code histology based on a specimen from the primary site whenever available.
CS Extension/Histology (Pre-2007)--Bladder: Is the histology coded to 8010/2 [carcinoma in situ] or to 8130/2 [papillary transitional cell carcinoma, non-invasive] for a 2006 bladder tumor with a final path diagnosis of "mixed non-invasive papillary TCC and flat carcinoma in-situ" and is CS Extension coded to 01 [Papillary transitional cell carcinoma state to be noninvasive]or to 06 [Carcinoma in situ]? See Discussion.
If the correct code for histology is 8130/2 and CS Extension is 06, this combination does not pass NAACCR edits.
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.For tumors diagnosed prior to 2007, code CS Extension to 06 and histology to 8130/2. Override the NAACCR edit.
For cases diagnosed 2007-2014, 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.
CS Eval/Surgery of Primary Site--Colon: When the only procedure performed is a polypectomy, if there is NO tumor at the margins, should CS TS/EXT-Eval be coded as 3 and the surgery coded as a polypectomy?
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.Assign eval code 3. A polypectomy with no tumor at the margin meets the criteria for pathologic staging.
Code polypectomy in Surgery of Primary site in this case.
MP/H Rules/Recurrence--Breast: If the pathologist and oncologist call a 2007 lobular carcinoma that appears in a skin nodule of a mastectomy scar a recurrence of a patient's 1975 primary breast duct carcinoma, should we abstract this as a new primary? See Discussion.
According to the pathologist and oncologist, the change in histology is attributed to the present availability of E-cadherin, which was not available in 1975.
For cases diagnosed 2007 or later, abstract the 2007 diagnosis as a separate primary using rule M5.
Rule M5 applies to this case because it comes before rule M12. Furthermore, based on your statement, the answer presumes that the original tumor was duct carcinoma only, there was no lobular carcinoma present. This must be a new primary because there are two different histologies.
The 2007 MP/H rules were developed with input from clinicians. They advised that a subsequent breast tumor more than five years later is a new primary. It is important to apply the rules so that these cases are handled in a consistant manner across all registries.
Histology (Pre-2007)--Breast: How is "invasive lobular carcinoma with signet ring cell features (95%) and ductal features (5%)" coded for a single tumor diagnosed prior to 2007?
For cases diagnosed 1/1/04-12/31/06, code histology to 8524 [Lobular mixed with other types of carcinoma]. Assuming there is no mention of in situ, Histology Coding Rule 3 applies: Use a mixed histology code if one exists
For cases diagnosed 2007-2014, 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.
Reportability--Hematopoietic, NOS: The Abstracting and Coding Guide for the Hematopoietic Diseases, page 47, states to determine whether the physician is using the term myelodysplasia to describe bone marrow marrow malfunction or a neoplasic syndrome in order to determine reportability. What do we do when there is no information one way or the other?
For cases diagnosed prior to 1/1/2010:Without further information, the term "myelodysplasia" alone is not reportable. If a more definitive diagnosis is made later, the case may become reportable.
For cases diagnosed 1/1/10 and later, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
Radiation Therapy: How is radiation coded when it is "recommended" but the patient dies before radiation is started? See Discussion.
Code 0 seems appropriate but then we would lose the fact that it had been recommended. All of the other modalities give an option for 'recommended but patient died prior to treatment.' Is there a reason this option is not given for radiation?
Code Radiation (Rx Summ--Radiation) to 0 [None; diagnosed at autopsy].
SEER does not collect the Reason For No Radiation field. However, those who abstract using software that captures this data item can identify these cases. Code 5 [radiation not administered because patient died] reflects this situation.
Radiation (Rx Summ-Radiation) is a SEER field. This field is derived from the data collected in Rad-Boost Rx Modality and Rad-Regional TX Modality. These fields do not include a choice for "radiation not given because the patient died prior to treatment." Therefore, this information cannot be coded in the Radiation field.
Multiplicity Counter--Thyroid: How is multiplicity counter to be coded for a thyroid cancer presenting as multiple foci? See Discussion.
Thyroidectomy showed papillary thyroid carcinoma. Path diagnosis: tumor focality: multifocal. Path described 3 foci of tumor on each side. The main tumor mass in right thyroid was 1.5 cm. Smaller foci of tumor ranged in size from .1 cm to 1.0 cm. Per guidelines, "we still don't count foci as tumors for the purpose of these rules, even if there is more than one." The 1 cm tumor was probably macroscopic in size. Do we count it in the multiplicity counter? Do we count only the 1.5 cm main tumor mass?
If the number of tumors is known, code the number in Multiplicity Counter. If foci are measured, include them in the multiplicity counter. If the only information available is "multiple foci" assign code 99.
For the case above, code 06 in the multiplicity counter (3 tumors on each side).