Q: How you would code SSF#4 (Tumor Deposits) for a colon primary when you have a polypectomy and no other surgery. The tumor was in-situ. Is this coded to 000 for none or is it more appropriate to code to 998 for a polypectomy for no surgical resection of the primary site was performed? A: Code to 998, No surgical resection of primary site. A polypectomy…
Q&A: “What is the grade for a patient diagnosed in 2014 with a Gleason reported as 3+4 = 7?”
2014 Instructions for Coding Grade Q: What is the grade for a patient diagnosed in 2014 with a Gleason reported as 3+4 = 7? A: The grade would be coded to a grade code of 2 for a Gleason score of 7 per the instructions for coding grade for 2014+ This is one of the grade changes effective for 1/1/2014 diagnoses http://seer.cancer.gov/tools/grade/
Q&A: “Do you have to have a prostate BX to have a clinical T?”
Q: “Do you have to have a prostate BX to have a clinical T? Patient presented to facility for radiation only. Patient had prostatectomy elsewhere. DRE and imaging noted to be negative. PSA prior to surgery was 7. BX not noted but not clear if it wasn’t done or just not noted in the medical record. Can we assign the T1 based on the negative imaging…
Q&A: Regional Nodes Examined
Q: A patient diagnosed with breast cancer by a core biopsy of a supraclavicular lymph node followed by a mastectomy with seven axillary lymph nodes removed. How do you code regional nodes examined, 07 or 08? A: Code 08, per CS general instructions if the positive aspiration or core biopsy is from a node in a “different” node region, include the node in the count of…