CANCER SURGERYABSTRACTORS TRAINING

CANCER SURGERY

Many types of cancer can be partially or totally removed from the human body by means of surgical treatment. The type of surgery is dictated by the primary site, type of cancer, clinical stage of disease, age/condition of patient, & so on….

OBTAINING THE DIAGNOSIS:

Most cancers are first biopsied in order to determine tumor type.

Incisional biopsies extract small portions of tumor for microscopic examination.

Excisional biopsies remove the tumor mass as a whole.

NON-DEFINITIVE SURGERY

Create “N” for coding incisional biopsies that produce malignant tissue.

Additional non-definitive surgery descriptions are shown on the following slide.

Non-Definitive Surgery Codes

01 Incisional biopsy of other than primary site

leaving gross residual disease. Needle biopsy of other than primary site. Aspiration biopsy of other than primary site.

02 Incisional biopsy of primary site leaving gross residual disease. Needle biopsy of primary site. Aspiration biopsy of primary site (must obtain tissue to be recorded).03  Exploratory ONLY (no biopsy)

NON-DEFINITIVE SURGERY CODES (CONT’D)

04 Bypass surgery (no biopsy); - ostomy ONLY (no biopsy)

05 Exploratory ONLY & incisional or needle biopsy of primary site or other sites

06 Bypass surgery & incisional or needle biopsy of primary site or other sites, ostomy ONLY, & incisional or needle biopsy of primary site or other sites

07 Non-definitive surgery, NOS

DO NOT CREATE “N” FOR:Cytology results only, such as from:

Fine needle aspirations Brushings & washings from

bronchoscopy Peripheral blood smears Regional lymph node

aspirations Excisional biopsies Incisional biopsies with

negative results

RULE FOR RECORDING NON-DEFINITIVE BIOPSY WHEN MORE THAN ONE BIOPSY IS PERFORMED:

Record the first positive, non-definitive tissue biopsy. If a positive biopsy is performed from both the primary site and a metastatic/non-primary site, record the biopsy from the primary site. Do not record negative biopsies.

“N” TREATMENT FIELDSType of Tx “N”Course of Tx “F”Date Tx started 03/15/09Tx facility 510375Tx at this facility? “0”Tx code “02”Tx text “Sigmoid

bx”

DEFINITIVE SURGICAL THERAPYCreate “S” for all definitive cancer surgeries.

Definitive surgeries remove malignant tumors, although margins may not be negative.

Excisional biopsy is one example of definitive surgery.

SURGERY TREATMENT FIELDSTx Type “S”Tx Course “F”Date Tx Started 03/15/2009Tx FacilityTx Local Hosp IDSurgery Primary Site (FORDS)Scope Regional LN (FORDS)Surgery Other Site (FORDS)Surgical Margins (FORDS)Tx Notes

COURSE OF TREATMENT

First course = “F” Subsequent course = “S”

DATE OF SURGERY

Carefully code the exact date on whichthe first course surgery took place.

On path reports, this is often the sameas the date the specimen was receivedby the lab (may also be date collected).

TREATMENT FACILITY

Enter the facility name or code where

the surgery took place.(See Appendix F of CPDMS abstractor’s

manual.)

TREATMENT LOCAL HOSPITAL ID

Enter code indicating whether or not this surgery was performed at YOUR facility.

“0” = Not at your facility “Hosp ID” = Hospital name “9” = Valid for diagnoses

BEFORE 1/1/03 only.

SURGICAL PROCEDURE OF PRIMARY SITE Site-specific codes located in Appendix G of

CPDMS Abstractor’s Manual & Appendix B of FORDS Manual.

Most common codes range from “00” to “79”. Codes “80” and “90” are only rarely used

when precise information is unavailable. Bx’s that remove all tumor or leave

microscopic margins are coded here even if documented as “incisional” bx’s.

When previous surgery removes part of primary tumor & additional surgery removes remainder of primary tumor, code “total results”.

SURGERY PRIMARY SITE

Colon Rectosigmoid Rectum Anus

COLON (C18.0-C18.9)

00 No surgery of primary; autopsy only10 Local tumor destruction, NOS 11 Photodynamic therapy (PDT) 12 Electrocautery; fulguration 13 Cryosurgery 14 LaserNO SPECIMEN SENT TO PATHOLOGY fromsurgical events 10-14

COLON (CONT’D)20 Local tumor excision, NOS 27 Excisional biopsy 26 Polypectomy, NOS 28 Polypectomy – endoscopic 29 Polypectomy – surgical excision Any combination of 20 or 26-29 WITH 21 Photodynamic therapy (PDT) 22 Electrocautery; fulguration 23 Cryosurgery 24 Laser ablation

25 Laser excision

COLON (CONT’D)30 Partial colectomy, segmental resection 32 Plus resection of contiguous organs;

example: small bowel, bladder40 Subtotal colectomy/hemicolectomy (total right

or left colon and a portion of transverse colon) 41 Plus resection of contiguous organ;

example: small bowel, bladder50 Total colectomy (removal of colon from cecum

to the rectosigmoid junction; may include a portion of rectum)

51 Plus resection of contiguous organ; example: small bowel, bladder

COLON (CONT’D)

60 Total proctocolectomy (removal from cecum to entire rectum)

61 Plus resection of contiguous organ; example: small bowel, bladder

70 Colectomy or coloproctotectomy WITH resection of contiguous organ(s), NOS (where there is not enough information to code 32, 41, 51, or 61)

80 Colectomy, NOS90 Surgery, NOS99 Unknown if surgery performed; death certificate

ONLY

COLON CODING PRACTICE

1. Pt underwent colonoscopy with polypectomy & was diagnosed with atubular adenoma containing microinvasive adenocarcinoma. Margins clear. Surgery code?

2. Pt underwent sigmoidectomy for mucinous adenocarcinoma of sigmoid colon. Surgery code?

RECTOSIGMOID (C19.9)

00 No surgery of primary; autopsy only10 Local tumor destruction, NOS 11 Photodynamic therapy (PDT) 12 Electrocautery; fulguration 13 Cryosurgery 14 LaserNO SPECIMEN SENT TO PATHOLOGY fromsurgical events 10-14

RECTOSIGMOID (CONT’D)

20 Local tumor excision, NOS 26 Polypectomy 27 Excisional biopsy Any combination of 20 or 26-27 WITH 21 Photodynamic therapy (PDT) 22 Electrocautery; fulguration 23 Cryosurgery 24 Laser ablation

25 Laser excision

RECTOSIGMOID (CONT’D)30 Wedge or segmental resection; partial proctosigmoidectomy, NOS Procedures coded 30 include, but are not limited to:

Anterior resectionHartmann’s OperationLow anterior resection (LAR)Partial colectomy, NOSRectosigmoidectomy, NOSSigmoidectomy

40 Pull through WITH sphincter preservation (coloanal anastamosis

RECTOSIGMOID (CONT’D)

50 Total proctectomy51 Total colectomy55 Total colectomy WITH ileostomy, NOS

56 Ileorectal reconstruction57 Total colectomy WITH other pouch; example:

Koch pouch60 Total proctocolectomy, NOS

65 Total proctocolectomy WITH ileostomy, NOS66 Total proctocolectomy WITH ileostomy and pouchRemoval of the colon from the cecum to the rectal sigmoid or a portion of the rectum.

RECTOSIGMOID (CONT’D)

70 Colectomy or proctocolectomy resection in continuity with other organs; pelvic exenteration

80 Colectomy, NOS; proctectomy, NOS90 Surgery, NOS99 Unknown if surgery performed; death certificate only

RECTOSIGMOID CODING PRACTICE

1. Pt chose to undergo low anterior resection of sigmoid colon for adenocarcinoma. Surgery code?

2. Total proctectomy was the treatment selected for adenocarcinoma of the sigmoid colon. Surgery code?

RECTUM (C20.9)00 No surgery of primary; autopsy only10 Local tumor destruction, NOS 11 Photodynamic therapy (PDT) 12 Electrocautery; fulguration 13 Cryosurgery 14 LaserNO SPECIMEN SENT TO PATHOLOGY fromsurgical events 10-14

RECTUM (CONT’D)

20 Local tumor excision, NOS 27 Excisional biopsy 26 Polypectomy Any combination of 20 or 26-27 WITH 21 Photodynamic therapy (PDT) 22 Electrocautery; fulguration 23 Cryosurgery 24 Laser ablation

25 Laser excision 28 Curette and fulguration

RECTUM (CONT’D)30 Wedge or segmental resection; partial proctectomy, NOS Procedures coded 30 include, but are not limited to:

Anterior resectionHartmann’s OperationLow anterior resection (LAR)Transsacral rectosigmoidectomyTotal mesorectal excision (TME)

40 Pull through WITH sphincter preservation (coloanal anastamosis

RECTUM (CONT’D)50 Total proctectomy Code 50 includes, but is not limited to:

Abdominoperineal resection (Miles procedure – AKA APR)60 Total proctocolectomy, NOS70 Proctectomy or proctocolectomy resection in

continuity with other organs; pelvic exenteration

80 Proctectomy, NOS90 Surgery, NOS99 Unknown if surgery performed; death

certificate only

RECTUM CODING PRACTICE

1. Pt underwent APR of adenocarcinoma of rectum. Surgery code?

2. Pt underwent polypectomy with fulguration for adenocarcinoma in situ arising in a polyp. Margins clear on pathology report. Surgery code?

ANUS (C21.0-C21.8)

00 No surgery of primary; autopsy only10 Local tumor destruction, NOS 11 Photodynamic therapy (PDT) 12 Electrocautery; fulguration 13 Cryosurgery 14 Laser

15 Thermal ablationNO SPECIMEN SENT TO PATHOLOGY fromsurgical events 10-15

ANUS (CONT’D)20 Local tumor excision, NOS 26 Polypectomy 27 Excisional biopsy Any combination of 20 or 26-27 WITH 21 Photodynamic therapy (PDT) 22 Electrocautery; fulguration 23 Cryosurgery 24 Laser ablation

25 Laser excision

ANUS (CONT’D)60 Abdominal perineal resection, NOS (APR; Miles Miles procedure) 61 APR and sentinel node excision 62 APR and unilateral inguinal node dissection 63 APR and bilateral inguinal node dissection90 Surgery, NOS99 Unknown if surgery performed; death certificate ONLY

ANUS CODING PRACTICE

1. Elderly male with change in bowel movements and blood from rectum underwent transanal excsion of a superficial anal mass. Pathology reported adenocarcinoma in situ. Surgery code?

2. 59 y/o male with biopsy-proven rectal adenocarcinoma chose to undergo APR and sentinel node biopsy. Surgery code?

Remaining Surgery Fields – All Sites

SURGICAL APPROACH

Record the surgical method used toapproach the primary site at this facility.

SURGICAL APPROACH CODES0 No surgical procedure of primary site at this

facility; diagnosed at autopsy1 Robotic assisted2 Robotic converted to open3 Endoscopic4 Endoscopic converted to open5 Open or approach unspecified6 Unknown whether surgery was performed

at this facility

SCOPE OF REGIONAL LN SURGERY

Record the removal, biopsy, or aspiration ofregional lymph node(s) at the time of surgery of the primary site or during aseparate surgical event.

SCOPE OF REGIONAL LN SURGERY Codes:0 No regional lymph node surgery; no lymph nodes found in the pathologic specimen; or diagnosed at autopsy 1 Biopsy or aspiration of regional lymph node(s)2 Sentinel lymph node biopsy; attempted

sentinel lymph node biopsy3 Number of regional nodes removed unknown

or not stated; not specified as sentinel nodes4 1-3 regional nodes removed; not specified as

sentinel nodes                          

SCOPE OF REGIONAL LN SURGERY

Codes (cont’d):5 4 or more regional nodes removed; not specified

as sentinel nodes6 Sentinel node biopsy performed OR attempted

AND code 3, 4, or 5 performed at same time, or timing not specified

7 Sentinel node biopsy performed OR attempted AND code 3, 4, or 5 at different times

9 Unknown whether regional nodes removed; death certificate-only; lymphomas with LN as primary site; hematopoietic diseases; unknown primary

SURGICAL PROCEDURE/ OTHER SITERecord the surgical removal of distantlymph nodes or other tissue(s)/organ(s)beyond the primary site.

SURGICAL PROCEDURE/ OTHER SITECodes:0  No surgical procedure of nonprimary site

performed; diagnosed at autopsy1  Nonprimary surgical resection to other site(s), unknown whether site(s) regional OR distant.2  Nonprimary surgical procedure to other regional sites3  Nonprimary surgical procedure to distant lymph node(s)4  Nonprimary surgical procedure to distant site5  Any combination of surgical procedures 2, 3, or 49  Unknown; death certificate only

SURGICAL MARGINS

Describes status of surgical margins after resection of primary tumor.

Microscopic can’t be seen with naked eye.Macroscopic can be seen with naked eye.Must code this data item from pathology reports. Carefully

check path reports for statement of margin status.

SURGICAL MARGINS CODESCodes:    0 No residual tumor 1     Residual tumor, NOS  2     Microscopic residual tumor3     Macroscopic residual tumor 7     Margins not evaluable                    8     No primary site surgery9     Unknown or not applicable                                                    

TREATMENT NOTES

Type in treatment descriptions using accepted abbreviations (Appendix H).

Can show additional information, such as “estimated date”, in this field.

If complete treatment information is documented in this field, you don’t have to repeat the same information in the text.

BEGIN PRACTICAL EXERCISES….

jm/rp/ss