Scenario: Surgeon Op Note: Procedure(s): LEFT MASTECTOMY, SENTINEL LYMPH NODE BIOPSY, LEFT AXILLARY LYMPH NODE DISSECTION Surgical Technique: Skin incision was made to include the area of retracted skin in an ellipse superior to the nipple. Plastic Surgeon Note: Procedure(s):1) RIGHT…
Scenario: 06-18-2020 Ovarian primary TAH/BSO- endometrioid adenocarcinoma-FIGO grade 1, however, focal areas (1-2%) with high nuclear grade, consistent with FIGO grade 2 Question: How would the pathological grade be coded? 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G3:…
Scenario: Below is a snip of the path report from a TURB, No actual statement of margins status mentioned on the path report. 6-20-20 TURB Path: FINAL DIAGNOSIS BLADDER TUMOR (BIOPSY): - Low-grade papillary urothelial carcinoma - No evidence of…
Scenario: 05-01-2019 MRI Pituitary gland: IMPRESSION: 3.7 mm Microadenoma seen in the left pituitary gland 05-29-2019 Neurologist Typically microadenomas do not cause symptoms and not progressive, will continue to follow with serial imaging 05-15-2020 Neurologist: Microadenoma appears stable on CT…
Scenario: 05-05-2020 -05-08-2020 LUL 5400cGy in 3 fractions (1800 cGy/fx) 10 MV hyperfractionated IMRT based stereotactic body radiotherapy Question: How would Phase I External Beam Radiation Planning Technique be coded? 05 Intensity modulated therapy (IMRT) 06 Stereotactic radiotherapy or radiosurgery,…
Scenario: 4-10-2020 CT Abdomen/Pelvis: Bilobed hypoenhancing mass within the pancreatic body/tail compatible with a primary pancreatic malignancy. Metastatic disease could have a similar appearance. 04-09-2020 CA 19-9 28,600 U/mL HIGH Managing Physician Statement: Metastatic cancer most likely pancreatic origin. I…
Scenario: 11/1/2019 Bone Marrow Biopsy: Hypercellular marrow (60-70%) w/ mature trilineage hematopoiesis. 10% clonal plasma cells identified. See Note: Serum protein electrophoresis with immunofixation showed a monoclonal IgG lambda. The serum calcium is increased (9.9 mg/dl, < 11mg/dl, does not…
Sorry for the length, but these 3 scenarios are important to illustrate some very important concepts. When these nodal biopsies get coded incorrectly, it affect several fields and can cause a catastrophic ripple effect on the audit and data quality. …
Question: How would you code Race 1 and Race 2? 01 White 07 Hawaiian 25 Polynesian, Nos 99 Unknown Answer: Race 1 07 Hawaiian Race 2 25 Polynesian, Nos Rationale: Refer to SEER Appendix D Race And Nationality Descriptions to…
Scenario I: 2-28-2019 Colonoscopy: screening colonoscopy found 25mm polyp removed by piecemeal mucosal resection using snare. Pathology: Poorly diff Adenocarcinoma arising in a serrated polyp invading the submucosa. There is no mention of margins on the path report. Scans: No…