Wiki Primary vs Secondary vs In-Situ

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thompson819

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Hello all,

I am new to pathology coding. I have searched for hours, but cannot find a definitive answer.

If a path report states, for example, squamous cell carcinoma, BUT does NOT say primary, secondary or in-situ, then do we just code to reason for exam/test?

I do not see any guidelines that state going to primary. I have to pick between these three, (primary, secondary, in-situ), and if it isn’t stated then I do not know.

With whatever answer is posted, please post solid references.

Any help is appreciated!

Thanks
 

thompson819
I am presenting next week on the Neoplasm table (again). There are lots of questions out there no doubt.
What does the pathology report state that is solid (none of that consistent with or otherwise verbiage?)
Oh heck no, you do not code the reason for the exam. Take a look at your gross section. What did you receive? Skin, Soft Tissue, Bone, Etc...
You really want a SOLID reference. You show up to my next presentation on Neoplasm Table next Thursday. I will tell you.
Best,
Dana​

 
I wish I wrote down some of the verbiage. Either way, I was not taught about the “gross” section unfortunately. I look at the final dx which shows the dx for each specimen and its corresponding location where it was obtained. I have seen the term “in-situ” used for sure. But never “primary” or “secondary”. Since we are taught not to assume, then how do we determine this? I would be interested in attending, however I cannot find a link for the presentation within your local chapter events page. Can you post the link?
 
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