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 fulfill WHO definition of organ damage), however, immunostain performed on specimens A and B show ~10% plasma cells and flow cytometry show a clonal plasma cell population. Those findings are a borderline smoldering plasma cell myeloma. Clinical correlation is recommended.
Bone Marrow for Karyotype/FISH analysis (Cytogenetics): Negative for high risk cytogenetics.
11/15/19 Oncology Note Assessment/Plan: IgG Lambda Smoldering Myeloma. Low risk based on MAYO criteria. Recommend observation.
Question: How would the Schema Discriminator 1 be assigned?
- 0 Multiple myeloma, Myeloma, NOS, Non-secretory myeloma, Plasma cell lymphoma, Ultra-High Risk Smoldering MM
- 1 Smoldering plasma cell myeloma (SPCM), Asymptomatic plasma cell myeloma, Early myeloma
- 2 Other terminology describing myeloma, Unknown terminology used
Answer: 1 Smoldering plasma cell myeloma
Question: How would the SSDI High Risk Cytogenetics be coded?
- 0 High-risk cytogenetics not identified/not present
- 1 High-risk cytogenetics present
- 7 Test ordered, results not in chart
- 9 Not documented in medical record, High Risk Cytogenetics not assessed or unknown if assessed
- Leave BLANK
Answer: Leave BLANK
Rationale: Read the notes in the SSDI manual. Note 5: If Schema Discriminator 1: Plasma Cell Myeloma Terminology is coded to 1 or 9, leave this SSDI blank. *This note also appears in SSDI’s Serum Albumin Pretreatment Level, Serum Beta-2 Microglobulin Pretreatment Level, LDH (Lactate Dehydrogenase) Pretreatment Level