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Question: 20130082 Status

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

Ambiguous terminology/Histology--Heme & Lymphoid Neoplasms: How is histology coded when a skin of lip pathology report demonstrates neoplastic lymphoid infiltrate with small B cells, compatible with B-cell small lymphocytic lymphoma/chronic lymphocytic leukemia? See Discussion.

Ambiguous terminology is not used to code histology. What is the correct histology for this case? There was no other clinical statement from the physician regarding the histology following the release of the pathology report diagnosis.

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Code the histology to 9823/3 [chronic lymphocytic leukemia/small lymphocytic lymphoma]. This primary was accessioned based on reportable ambiguous terminology. The surgical pathology report was compatible with B-cell small lymphocytic lymphoma/chronic lymphocytic leukemia, “compatible with” is a reportable ambiguous term. A neoplastic lymphoid infiltrate is not a reportable diagnosis. Therefore, a diagnosis compatible with CLL/SLL is coded as histology code 9823/3.

The statement that you do not use ambiguous terms to code histology is intended for those NOS histologies with an ambiguous term being used to describe the subtype.

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.

Assign 9823/3, SLL/CLL, because the surgical pathology report states the presence of the small B cells along with the ambiguous terminology of CLL.

We consulted our expert pathologist on this question. Per the Hematopoietic database, SLL/CLL is defined by the presence of small round B lymphocytes.

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