Wiki Path report Prime or mets

[JTE79]

What is the rule for coding if the path determines the diagnosis is cancer but is unable to determine primary or mets. The patient has a previous diagnosis of colon cancer. Has been diagnosed with ovarian cancer but the path is inconclusive if primary or mets from known colon.
The note states this.....
FINAL DIAGNOSIS
A. PELVIS, RECTAL/PERI-RECTAL, CT GUIDED FINE NEEDLE ASPIRATION:- ADENOCARCINOMA (SEE COMMENT)
Clinical Diagnosis and History
The patient is a 49 year old woman with pelvic mass and rectal/peri rectal mass. ?ovarian cancer? colon cancer?

Can't code uncertain behavior as it is cancer. What is the rule for coding this? Any help very much appreciated.
Thanks,
Jennifer

 

[danachock]

Primary vs Mets

Hi Jennifer,

Your diagnosis states: A. PELVIS, RECTAL/PERI-RECTAL, CT GUIDED FINE NEEDLE ASPIRATION:- ADENOCARCINOMA (SEE COMMENT)
*what did the comment state?

Without knowing what the comment states & based on your final diagnosis you will want to follow the General guidelines for Neoplasms found in the beginning of your ICD 9 book. It states "if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate."

With the information you have, you would go to the Index and look up Adenocarcinoma which states - see also Neoplasm, by site, malignant. This would be coded as a primary. Unless the pathology report states its mets you will code it primary.

Hopefully this helps,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology & Laboratory Coder