GENERAL CODING. When you review old cases that were coded to unknown, make corrections based on guidelines in effect at the time of diagnosis.

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1 GENERAL CODING When you review old cases that were coded to unknown, make corrections based on guidelines in effect at the time of diagnosis. Exception: You must review and revise EOD coding for prostate cases diagnosed on or after January 1, 1995 to ensure that EOD Extension codes 33 and 34 are used instead of 31. All treatment modalities such as surgery, radiation, and hormones, can be administered for any stage. If the only information you have is a report showing cancer in the prostate and there is no mention of extraprostatic disease, assign code 30, localized, NOS, rather than unknown. Codes are all localized disease and are not hierarchical (the numerically higher code is not the preferred choice). Choose the code that best describes the individual case. Code clinically inapparent tumors as 10, or 13-15; clinically apparent tumors as 20 or 23-24; and unknown if inapparent or apparent to 30. SEER has provided a list of terms in the Extent of Disease Manual, Third Edition, page 135, to assist in distinguishing apparent from inapparent tumors. DIAGNOSIS DATE If the medical record states that a patient was newly or recently diagnosed and the date of diagnosis is not stated, code diagnosis date to the date of admission Exception: For history-only cases, do not use the date of admission; instead, determine the date of diagnosis. CLINICAL EOD Code what you do know even if the workup is not complete. If the only information you have is a pathology report from a prostate needle biopsy, code the clinical extension 30, localized NOS, rather than unknown. Adhere to the EOD terminology in the SEER Coding Manual when coding EOD/Stage. If a term is a term of involvement, code the extension. Do not use terms of non-involvement to code stage. Example 1: Needle biopsy of the prostate shows adenocarcinoma. Bone scan shows possible metastasis. Possible is a term of non-involvement. The case is coded to localized rather than distant or unknown (EOD clinical extension is coded 11-30, depending upon the procedure and available information.) Exception: If the patient is treated for extension or metastasis, use that information to code the EOD extension even if the terminology is one of non-involvement. Example 2: The bone scan shows possible metastasis in the lumbar spine. The physician orders radiation to the lumbar spine. Code the extension as 85 (metastatic) even though the term possible is one of non-involvement. Statewide Distribution June 27, California Cancer Registry

2 Only clinical information is used to assign clinical EOD, do not use information from the prostatectomy to code the clinical EOD. Example 3: Patient has a hard nodule extending bilaterally to the apex on PE. Clinical extension is coded to 34. Patient has a prostatectomy that shows cancer confined to left lobe and an adenoma in right apex. Pathologic extension is coded to 20, but clinical extension remains 34. PATHOLOGIC EOD Pathologic EOD uses all clinical information as well as the information from pathology reports, including the pathology from a needle biopsy. Example 4: On PE, a hard nodule extends bilaterally to the apex. Needle biopsy of right apex was positive. Patient then had a prostatectomy that showed cancer in left lobe only. Combine the information from the needle biopsy and the prostatectomy and code the pathologic EOD to 34 (T2). Clinically Inapparent Tumor Codes Note: These codes were created for special studies and need to be as uncontaminated as possible. Use these codes only if you are sure the cancer was not clinically apparent. Example 5: A physician statement of T1c prostate cancer would be a statement that the cancer was clinically inapparent. Please see the list of terms SEER has provided (EOD Manual, page 135) to assist in distinguishing clinically apparent from inapparent tumors. If you are not sure whether or not a case was clinically apparent, use code 30 (apparent or inapparent). GUIDELINES FOR SPECIFIC CODES Code 10 Use this code when the percentage of involved tissue is unknown. This code should be used when the only information you have is Stage A, NOS. Codes These codes are based on the percent of resected tissue involved at TURP. There must be some statement indicating the percent of tissue involved. If the weight in grams is given for both the total amount of tissue resected and the tissue containing tumor, calculate the percentage by dividing the grams of tumor tissue by the grams of tissue resected. If weight is not given, use the number of involved chips and the total number of chips to calculate the percentage. Example 6: If the pathology states there are 3/40 chips involved, Divide 3 by 40 = 7.5%. Code to 14 (incidental finding in more than 5% of tissue resected). Assume that all chips and positive foci are of equal size. If the pathology report states solitary focus of carcinoma without mentioning the total amount of tissue resected, code the case to 13. Note: For coding purposes, the terminology tissue examined is synonymous with tissue resected. Statewide Distribution June 27, California Cancer Registry

3 When to use code 15 vs codes (How to determine if there is sufficient information to code to 15) Code 15 is for cases diagnosed on prostate needle biopsy. Use code 15 when the following criteria are met: There is documentation that the PSA was elevated or there is no documentation about the PSA. AND There is documentation that the physical exam was negative AND If a TRUS was done, there is documentation that the findings were negative. Use codes 30-34: The prostatic apex is involved OR When there is no documentation saying that physical exam was benign OR When there was a TRUS but there is no documentation that the examination was negative. Inapparent or Apparent Tumor (Please see guidelines for determining whether a case should be coded to 15 or 30.) EOD clinical extension should rarely be coded to 31. If you know only the apex is involved, it should be coded to 33 (arising in prostatic apex). If there is involvement of the apex and any other area of prostate, and there is no mention that it arose in the apex, it should be coded to 34 (extending into prostatic apex). Code 31 should only be used when you have a statement that the apex is involved, but you have no detailed documentation (such as a path report or a clinical description of the path findings) to verify whether it fits into code 33 or 34. When involvement of the apex is mentioned clinically and there are multiple positive prostate biopsies without mention of which areas of the prostate were biopsied, code to 34. Example 7: Coding to 33: PE: Admit for prostatectomy. Adenocarcinoma, right apex and possibly left mid prostate. The pathology from the biopsy is not available. Example 8: Coding to 34: PE: Admit for prostatectomy. Adenocarcinoma of prostate, present on the right side and crosses the midline to the left apex. The pathology from the biopsy is not available. PE: Admit for treatment consult. Medical record documents that biopsies of the right base, mid gland and apex were positive for adenocarcinoma. The pathology from the biopsy is not available. PE: US single hypoechoic lesion, left apex. Pathology report: Multiple biopsies on left, adenocarcinoma. No mention of which areas were biopsied. Statewide Distribution June 27, California Cancer Registry

4 Code 90 EOD clinical extension will rarely be coded to 90. Cases coded to 90 will probably be limited to: History only cases Death certificate only cases PSA elevated above 50 and absence of other information for coding EOD Incidental finding on prostatectomy or autopsy. Code 90 would be used here even if there were a prostate exam, because prior to an incidental finding the physician has no suspicion that there is a malignancy (there has been no needle biopsy or TURP). Example 9: Cases to be coded to 90: Patient has cystoprostatectomy for bladder cancer and prostate exam prior to surgery was benign. Patient has suprapubic prostatectomy because of urinary retention and BPH. Prostate ca is not suspected. EOD PATHOLOGICAL EXTENSION Question asked of SEER: At prostatectomy, seminal vesicles and margins are involved. Should extension be code 45 or 48? Answer: Use code 48. EOD LYMPH NODES Clinical Information Only Code lymph nodes as not involved (0) when the only information available is clinical (from scans and physical examination) and any of the following terms are used to describe the lymph nodes: Lymphadenopathy Enlarged nodes No lymphadenopathy No enlarged nodes Exam of lymph nodes within normal limits (WNL) Exam of lymph nodes negative Note: This list is intended as an example, it does not list all negative terms. No Clinical or Pathologic Information When there is no clinical or pathological information on LN s, use code 0 (none) when clinical and /or pathological extension is coded from If clinical and/or pathological extension is coded from 40-90, use code 9 (unknown). Use the following guidelines for coding PSA: PSA = 10.0 or above, code = 1 (positive/elevated) PSA = 4.0 and below, code = 2 (negative/normal) PSA = ; code = 3 (borderline) PSA Note: Physician statement has priority over recorded values. If the physician states that the PSA is elevated or that there has been a significant rise in PSA, code to 1 (elevated). Generally PSA level will only be used to assist in coding EOD if it is very elevated (above 50). In the absence of other EOD information, if the PSA level is above 50 do not code the case to localized. Statewide Distribution June 27, California Cancer Registry

5 Example 10: H&P: Admit for multiple medical problems. PSA on admission was 258. DX: Probable prostate cancer. Patient s family wishes no further work-up. EOD clinical extension should be coded to 90. Statewide Distribution June 27, California Cancer Registry

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