CTR Coding Break – Cytology Exceptions with Case Examples


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The July 2021 CTR Coding Break reviews cytology exceptions outlined in the STORE manual 2021 and the SEER Program Coding and Staging Manual 2021. There are various types of cytological examinations. One example is a fine needle aspiration which uses a thin needle inserted into the lesion or area to remove fluid. This is different from a core needle biopsy which removes tissue to be microscopically examined.

When a workup scan uses correct ambiguous terminology to describe a malignancy, this can be used as a diagnosis date however when a cytology uses correct ambiguous terminology, this cannot be interpreted as a diagnosis. When a cytology is performed with correct ambiguous terms but does not have any confirmation of a positive cancer by a positive biopsy or a physician statement, this cannot be reportable. When a urine cytology is stated as positive without any further information, the primary site is coded to C68.9. When a lymph node cytology is performed that is regional to the primary site, this is coded into the scope of regional lymph nodes data field as code 01.

If you would like to download this month’s presentation as a PDF click here.