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Question: 20130028 Status

Source 1:   Heme & Lymph Manual & DB
Source 2:  

Primary site--CLL/SLL: How is the primary site coded and what rule applies when no bone marrow biopsy is performed on a patient diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) which was based on the results of an axillary biopsy, positive peripheral blood and a CT scan showing multiple lymph nodes involved above and below the diaphragm? See Discussion

The physician staged this as Stage 0 CLL/SLL. Should the primary site be coded to lymph nodes if the MD stated this was leukemia?

For cases diagnosed 2010 and forward, access the Hematopoietic Database at

Code the primary site to C421 [bone marrow] per Rule PH5. Code the primary site to the bone marrow when the peripheral blood is involved, even if no bone marrow biopsy is performed.

According to the notes for Rule PH5, CLL always has peripheral blood involvement (PH5 Note 1). CLL/SLL may also have involvement of lymph node regions in later stages (PH5, Note 2). For this patient a bone marrow biopsy was not performed but he had extensive lymph node and peripheral blood involvement. Therefore, the primary site is coded to C421. In addition, the physician’s documentation specifies this patient has Stage 0 disease which indicates this disease process is being classified as leukemia (CLL).

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.

Code to bone marrow, C421.

Do not rely solely on the database. Always consult the manual and follow instructions there. Use the database as instructed in the rules.

Module 3 applies to this case based on the diagnosis of CLL/SLL. Start with the first rule in the module, Rule PH8, and stop there because PH8 fits this case.

According to the notes for Rule PH8, CLL always has peripheral blood involvement, as noted in your case (PH8 Note 1). CLL/SLL will have involvement of the lymph node regions (PH8 Note 3). Since there is extensive lymph node involvement and peripheral blood involvement in your case, code primary site C421, even though the bone marrow biopsy was not done.

The physician's documentation as Stage 0 corresponds with this case being classified as a leukemia.

In terms of the questions regarding the notes: Note 1: Since there is peripheral blood involvement, this would be CLL and assigned primary site C421. Bone marrow biopsy results are not required since there is peripheral blood involvement. Note 2: This is for SLL only. Does not apply in this situation. Note 3: This is further information about CLL/SLL, which your case fits (extension lymph node involvement). Note 6: Use Module 7 when you are coding lymphomas. If the peripheral blood was negative, this would have been SLL (lymphoma) based on the description. You would then use Module 7 to help assign primary site.

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