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STORE surgery coding for breast revised

Scenario:Patient diagnosed with invasive ductal carcinoma of the right breast, treated with Bilateral total (simple) mastectomy & sentinel lymph node biopsy.

Question:  Would you code the removal of the uninvolved contralateral breast under the data item Surgical Procedure/Other Site?

Answer:  NO!

Rationale: 8-22-2019 The Brief

TIP: Cut/Paste this information into a Sticky Note in your saved copy of the STORE. Cross out this instruction in orange on page 468 & 469 

STORE surgery coding for breast revised

The surgery coding instructions for the breast primary site will be updated in the next STORE 2018 revision to reflect the following:

  • A total (simple) mastectomy removes all breast tissue, the nipple, and areolar complex. An axillary dissection is not done, but sentinel lymph nodes may be removed.
  • For single primaries involving both breasts use code 76.
  • If the contralateral breast reveals a second primary, each breast is abstracted separately. The surgical procedure is codded 41 for the first primary. The surgical code for the contralateral breast is coded to the procedure performed on that site.

The prior instruction in FORDS/STORE for single primaries only — code removal of the contralateral breast under the data item Surgical Procedure/Other Site (NAACCR Item #1294) and/or Surgical Procedure/Other Site at This Facility (NAACCR Item #674) — will be removed. It is not applicable.

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