Coding surgical margins is sometimes challenging. Below are some tips to assist in coding this field.
- Record the margin status as it appears in the pathology report
- Code 7 if the pathology report indicates the margins could not be determined
- Code 9 if the pathology report makes no mention of margins or no tissue was sent to pathology.
- Code 1 if involvement is indicated but not otherwise specified (Residual Tumor NOS).
- Code 2 if a path report is available and indicates a positive margin seen microscopically
- Code 3 if a path report is available and indicates a positive margin seen on gross exam.
Did you find this information useful? Chances are you know someone else who would as well! Feel free to share this blog with your colleagues for more tips from our Oncology and Quality Division teams!