The Surgical Diagnostic and Staging Procedure data field is most commonly assigned a code 02 for biopsy that obtains tissue of the primary site, as this is a direct way to identify the histologic type of cancer through a microscopic evaluation. But what about the less common Surgical Diagnostic Staging Procedure codes, such as code 05?
The Standards for Oncology Registry Entry (STORE) 2023 describes Surgical Diagnostic and Staging Procedure code 05 as an exploratory procedure performed and a biopsy of either the primary site or another site was done and provides the following example: an exploratory procedure for a primary colon carcinoma with a biopsy of suspicious liver lesions.
Some Cancer Registrars might wonder if a colonoscopy plus biopsy qualifies as a code 05 due to the procedure “exploring” the colon. A scope that is inserted into the natural body opening such as the mouth, anus or urethra is an endoscopic exam that allows for assessment of the interior of a hallow organ or cavity. A colonoscopy aids the physician in examining the mucosal walls of the colon. This is assigned a code 02 for a colon primary case. Another example of an endoscopic procedure would be a bronchoscopy for suspected lung cancer with biopsy obtained; this would also be coded to a 02, as the scope aided the physician in assessing the interior of the bronchus. Another situation where code 05 is sometimes erroneously coded when an incisional biopsy of a secondary site is obtained during a surgical procedure to the primary site. These procedures should be coded in the Surgical Diagnostic and Staging Procedure Field. Once surgical treatment has been initiated and non-primary site tissue is removed, this procedure becomes a Surgical Procedure of Other Site.
So, what is a surgical exploration and what does qualify for a code 05? An exploratory procedure involves an incision (usually in the abdomen) with the physician either grossly examining (laparotomy) or using a scope (laparoscopy) to aid in the examination of solid organs and the spaces between, looking for abnormalities in organ tissues and structures. When the procedure performed includes a biopsy, we would assign Surgical Diagnostic and Staging Procedure 05, for the exploratory procedure plus biopsy.
Furthermore, if there is a situation where surgery is planned and attempted but aborted, and then an exploratory laparotomy or laparoscopy is performed, this would qualify for a Surgical Diagnostic and Staging Procedure code 05.