Scenario: Patient has a partial nephrectomy and adrenal gland was not removed. Pathology report states clear cell adenocarcinoma, tumor is limited to the kidney.
Question: How is the SSDI for Ipsilateral Adrenal Gland Involvement coded?
- Code 0: There is no involvement of the ipsilateral adrenal gland.
- Code 9: No documented in medical record. Ipsilateral adrenal gland not resected. Ipsilateral adrenal gland involvement not assessed or unknown if assessed. No surgical resection of primary site is performed.
Answer: Code 0: There is no involvement of the ipsilateral adrenal gland.
Rationale: SSDI Manual Version 1.7 If tumor is “confined to kidney” and staging is based on size, then there is no involvement of the adrenal gland.
- The same changes have been made to Invasion Beyond Capsule, and Major Vein Involvement.