CODING QUALITY TIPS

Autumn greetings! There have been major updates and changes to the 2026 Hematopoietic and Lymphoid Neoplasm Coding Manual. The last major update was in 2014. It was clear to the standard setters that some of the rules caused confusion and misunderstanding.

The 2026 changes to the Hematopoietic and Lymphoid Coding Manual can be applied to cases diagnosed January 1, 2010, forward.

Overview of Changes to Hematopoietic and Lymphoid Neoplasm Coding Manual 2026

• No new rules or modules, no modules or rules deleted.
• Overhaul of structure (content not changed).
• New definitive terminology for assigning histology.
• New section introducing Hematopoietic Neoplasms
• Overhaul of several sections, including Steps for Using the Heme Manual and DB, Multiple Primaries Calculator, Transformations, Primary site coding instructions

and Treatment.

• New section added for Coding Mets at Dx fields for Hematopoietic neoplasms.
• Primary site assignments for each of the histologies have been removed from the Heme Manual. This information is in the Heme DB.
• Clarifications added on when and how to code histology based on positive immunophenotyping or genetics.
• Grade rules were removed. The grade rules are no longer applicable for Heme neoplasms (See Heme DB to assign grade for cases diagnosed prior to 2018).
• Lineage tables updated based on the WHO Blue Book, 5^th edition for Hematolymphoid Tumors (2024).
• New examples added based on Ask a SEER Registrar questions.
• New Appendix E: List of terms added to the Hematopoietic Database from the WHO 5^th edition of Hematolymphoid Neoplasms.

Important Changes to Multiple Primary Rules and Primary Site and Histology Rules (not a complete list)

• Confusing statements such as “Simultaneously” and “21 days” have been removed.
• There are two tables that have been added, one for Multiple Primary rules and one for Primary Site and Histology rules. These are “roadmaps” to help easily navigate through the rules as a guide and summary only. Coders must work through the hematopoietic and lymphoid rules to derive the correct histology and primary site.
• Several of the Multiple Primary rules now refer to “initial clinical workup,” which is the timeframe when patients are first diagnosed. The initial clinical workup may include blood work, imaging, biopsies (including bone marrow), and genetic testing. In some situations, the treatment may start before the full workup is completed.

Key Point:

Make sure to use the most updated version of the Hematopoietic and Lymphoid Coding manual by using the link rather than a bookmark. This will direct you to the newest revisions and changes available.

Examples

• PET scan shows cervical nodes lymphadenopathy only. Biopsy of cervical lymph node is diagnostic for EBV-positive diffuse large cell lymphoma and Classic Hodgkin lymphoma, NOS. This is a single primary C770, 9680/3.
  • Steps for working through the rules:
    • Refer to the Heme database: There are two preliminary histologies 9652/3 and 9680/3.
    • Next, use the M rules: RuleM5 states, when Hodgkin and NHL are in the same location at the same time, it is a single primary.
    • Do not use the multiple primaries calculator to determine number of primaries unless you are instructed to do so in the rules. Using the calculator first would show this is two primaries. Since we work through the rules first, we get to M5 and stop.
• Patient presents with multiple sites of lymphadenopathy. Scans show involvement of mediastinal mass, along with lymphadenopathy of hilar, bilateral axillary, upper abdominal/retroperitoneal lymph nodes. Also noted to have bone involvement of the lymphoma. Axillary lymph node biopsy diagnostic for T-cell/histiocyte rich large B-cell lymphoma. This is a single primary C778, 9688/3.
  • Steps for working through the rules:
    • Refer the Heme database: T-cell/histocyte rich large B-cell lymphoma shows a histology of 9688/3.
    • Next, use the M rules: M2, a single histology.
    • The Primary Site Coding Instructions state to set aside the common metastatic sites of bone, brain, liver, lung, and bone marrow and see what is left, which in this case leaves multiple lymph nodes involved.
    • Rule PH 21 instructs us to code C778, this is a single primary.

Bonus Tip:

Ambiguous terminology updates for coding histology for hematopoietic and lymphoid cases ONLY.

The following terms are now considered “definitive diagnoses” for hematopoietic cases and are no longer on the ambiguous terminology list for assigning histology.

• Comparable with
• Compatible with
• Consistent with
• Most likely
• Probable
• Typical (of)

Note: Do not apply these changes to casefinding, reportability or staging. (per Heme Manual 2026, Version 3.3, page 56).

References

Hematopoietic and Lymphoid Neoplasm Manual

https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf

Hematopoietic and Lymphoid Neoplasm Database

https://seer.cancer.gov/seertools/hemelymph/

Extent of Disease Mets

SEER Program Coding and Staging Manual 2026

High risk cytogenetics include detection of one or more of the following genetic mutations: t(4;14), t(14;16) or deletion of 17p. Please note, these are the only cytogenetics that apply for this site-specific data item (SSDI). High-risk cytogenetics are an important staging element for plasma cell myeloma (per Revised International Staging System [RISS]). A FISH (fluorescence in situ hybridization) test of the bone marrow is the diagnosis tool for these gene mutations.

According to the National Institute of Health (NIH), having one or more of these mutations typically predicts a poorer prognosis and outcome for the patient, thus showing the importance of capturing this data item. This SSDI applies to all plasma cell myeloma cases diagnosed 2018+.

Per the SSDI Manual:

• This SSDI can be coded from a physician’s statement or by reading the results of the FISH test, which should be in the pathology report (likely in an addendum).
• Ensure the test was performed during the diagnosis workup of the patient’s myeloma and prior to treatment.
• Note 1: “If the presence/absence of high-risk cytogenetics determined by available test results differs from the physician statement or presence/absence, the physician’s statement takes precedence.”
• Note 2: “Code 0 if the physician states that the RISS stage 1 or 2 and there is no other information”. If high-risk cytogenetics are not mentioned in the report or physician’s notes, code to 9. Do not assume the cytogenetics are negative unless stated.

Coding Examples

1. Physician states they are treating this patient more aggressively due to high-risk cytogenetic risk factors. Bone marrow FISH test shows normal results including no detection of 1p, t(4;14), and t(14;20).
   • Code high-risk cytogenetics SSDI to 1, cytogenetics detected per physician statement.
2. Patient with plasma cell myeloma, FISH shows detection of 1p deletion, 11q gain, and t(14;20) fusion; also shows no detection of t(4;14), 17p deletion, or t(14;16). Physician does not mention high-risk cytogenetics.
   • Code high-risk cytogenetics SSDI to 0, not identified/not present. No relevant genetic mutations were detected.
3. Physician states patient with plasma cell myeloma will be treated with Daratumumab and Revlimid. It is also stated that the patient had an abnormal FISH test resulting in detection of 11q gain and 1p deletion, no other results were mentioned. No other information is found in the path report.
   • Code high-risk cytogenetics SSDI to 9, physician did not mention the specific gene alterations and there were no FISH results in the pathology report.

KEY POINT:

The presence or absence of these genetic mutations is a critical component of staging in plasma cell myeloma. It determines the type of treatment the patient will receive and helps to evaluate the prognosis for the patient. Careful coding of these results will contribute to cancer research and further advancement of treatment.

BONUS TIP/Reminder

In addition to high-risk cytogenetics there are other prognostic factors which should be coded: Serum Beta-2 Microglobulin Pretreatment level, the Serum Albumin Pretreatment Level, and the LDH Level. Carefully document levels and units in the text fields and refer to the SSDI manual for proper coding.

REFERENCES

SSDI Manual: https://www.naaccr.org/wp-content/uploads/2025/12/SSDI-Manual-v3.3_printed.pdf?v=1780932631

• 00821-Plasma Cell Myeloma
• 3857: High Risk Cytogenetics

NIH: https://pmc.ncbi.nlm.nih.gov/articles/PMC9160142/

• Abstract

Hematopoietic manual: https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf

The Utah Cancer Registry occasionally receives abstracts on non-reportable cases that should not be submitted. Below are a few reminders about these types of cases.  Please note, this is not a comprehensive list of non-reportable cases.

Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)

• This histology was reportable 2017 through 2020 with a histology code of 8343/2.
• As of January 1, 2021, the histology and behavior changed to 8349/1 and is not reportable.
• Cases diagnosed 2021 forward with a histology code of 8343/2 should be reviewed and updated to the correct histology code of 8349/1, making them not reportable to the Utah Cancer Registry.

ICD-O-3 Coding Updates 2021 Table 5

Dermatofibrosarcoma protuberans, NOS

• This histology was reportable through 2020 with a histology code of 8832/3.
• As of January 1, 2021, the behavior code changed to /1, which makes this non reportable if stated to be
  • When dermatofibrosarcoma protuberans has a modifier, it may be reportable. The pathology text should be reviewed closely for modifiers such as fibrosarcomatous, with myoid differentiation, myxoid, plaque-like, and others, which would be coded to 8832/3.

ICD-O-3 Coding Updates 2021 Table 2

Teratoma

Female:

• Mature teratoma of the ovary is not reportable (9080/0).
• Ovarian teratoma with malignant transformation is reportable (9084/3) when a malignant histology arises in a benign teratoma also known as a teratoma with somatic-type malignancy.

Male:

• Pre-puberty: Mature teratoma of the testis is not reportable (9084/0)
• Post-puberty: Mature teratoma of the testis is reportable (9080/3)
• Unknown puberty: Do not report mature teratoma of the testis when it is not known whether the patient is prepubescent or postpubescent. Pubescence can take place over a number of years; review physical history and do not rely only on age.

Key Points:

• Review yearly implementation guidelines for coding changes.
• Refer to SEER Program Coding and Staging Manual and Appendix E for non-reportable lists and examples.

Bonus Tip

Although the following histologies have the word “carcinoma” in them, they are not reportable for thyroid primaries for diagnosis year 2021 and forward:

• Non-invasive EFVPTC (8349/1):
  • Carcinoma, encapsulated follicular variant of papillary thyroid carcinoma, non-invasive
  • Carcinoma, papillary thyroid, follicular variant, non-invasive encapsulated
  • Encapsulated follicular variant of papillary thyroid carcinoma, non-invasive

References

SEER Program Coding and Staging Manual:  Reportability and Appendix E- https://seer.cancer.gov/tools/codingmanuals/

Solid Tumor Rules: https://seer.cancer.gov/tools/solidtumor/

ICD-O-3 and annotated histology list: https://seer.cancer.gov/icd-o-3/

ICD-O-3 Implementation Guidelines, ICD-O3.2 Documents, Tables 1-5 https://www.naaccr.org/icdo3/#1752675260052-4c51088b-7959

SINQ 20210046, 20220018, 20230032, 20240013, 20210046 - https://seer.cancer.gov/seer-inquiry/

This month, we would like to share a reminder of histologies that are biologically impossible to arise in the kidney parenchyma.

Urothelial carcinoma of the upper urinary system usually arises in the renal pelvis C659 and not in the kidney C649. Per Note 2 of the Solid Tumor Rules 2026 Update, page 171. Urothelial carcinoma 8120 and papillary urothelial carcinoma 8130 are biologically impossible in the kidney.

Renal Pelvis C659 anatomy consists of calyx, pyelo-, renal pelvis, and renal sinus.  Kidney C649 anatomy includes Bowman’s capsule, cortex, glomerulus, medulla, nephro-, nephrons, pyramid, and renal papillae.

Coding Examples

1. Imaging revealed a 4.3 cm lesion in right renal upper pole collection system. The lesion extends into the right superior renal parenchyma and renal calyces; this is highly suspicious for urothelial carcinoma. Radical nephrectomy is diagnostic of a papillary transitional cell carcinoma.
   • Code Primary site to C659 per STR 2026 Update, Note 2, page 171 and Table 1: ICD-0 Primary Site Codes, page 357.
   • Code histology to 8130/3 per Rule H1 and STR 2026 Update, Table 2, Specific Histologies, NOS, and Subtypes/Variants, page 361.

2. Cystoscopy shows a large papillary tumor appearing in the left kidney upper pole, which involves most of the upper pole. The urethra and bladder are normal. Left nephroureterectomy with bladder cuff excision are diagnostic for chromophobe renal cell carcinoma.
   • Code primary site to C649 per ICD-0-3 and STR 2026 Update, Table 1: ICD-0 Primary Site Codes, page 357.
   • Code histology to 8317/3 per Rule H1 and STR 2026 Update, Table 1-Specific Histologies, NOS and Subtype/Variants, Page 175.

Key Point: Urothelial carcinoma 8120 and papillary urothelial carcinoma 8130 are biologically impossible to arise in the kidney parenchyma

Bonus Tip: Resources for Coding Primary Site for Solid Tumors, in priority order (per SPCM 2026, page 106):

• ICD-O
• SEER Program Coding and Staging Manual
  • Including Coding Guidelines in Appendix C
• Solid Tumor Rules (when extra guidance is included)

References:

Solid Tumor rules 2026 Update

https://seer.cancer.gov/tools/solidtumor/current/STM_Combined.pdf

Renal Pelvis, Ureter, Bladder, and Other Urinary Site-group Instructions. Table 1: ICD-O Primary Site Codes

https://seer.cancer.gov/tools/solidtumor/current/STM_Combined.pdf

Resources for Coding Primary Site for Solid Tumors, in priority order

https://seer.cancer.gov/manuals/2026/SPCSM_2026_MainDoc.pdf

Cancer PathCHART & ICD-O-4 Updates- Alison Van Dyke (SEER Workshop)

https://seer.cancer.gov/cancerpathchart/search/

This month, we are looking into reportability of basal and squamous cell cancers, specifically of the skin. Reportable cases are often missed when not checking thoroughly for the correct site.

Squamous and basal cell reportability for skin sites

Non reportable:

• Basal cell carcinoma of skin, C440-C449 with histology of 8090-8110
• Squamous cell carcinoma of skin, C440-C449 with histology of 8050-8086
• Squamous cell carcinoma of parotid gland with a clear statement that origin or primary site is skin.
• Squamous or Basal Cell Carcinoma of the perianal skin and anal skin (C445)
• Squamous or Basal Cell Carcinoma of the lip when it is not clear if the site is mucosa or skin:
  • For an overlapping lesion of mucosa and skin of lip, search available records for a clear statement of origin. Refer to Head and Neck Solid Tumor Rules “Coding Primary Site When There is Conflicting Information” for the priority order for determining primary site:
    • Tumor Board
    • Tissue/pathology from tumor resection or biopsy
    • Scans
    • Physician documentation
  • SINQ 20240030 clarifies how to report SCC that overlaps skin and the vermillion border when the percentage of overlap is unknown: “Determine whether the lesion is on the mucosa or skin based on the pathology report, history and physical, and operative notes when available. The gross description of the pathology report should include information to help in determining whether the site of origin is epithelium (skin) or mucosa (lip).

Do not report the case when the site of origin cannot be determined between a reportable site and non-reportable site for this histology. This includes situations where the site of origin or the site with the greatest involvement is undetermined.”

Reportable situations that are often missed:

• Sites that do not have skin codes including labia majora (C510), vulva (C519), penis (C609), and scrotum (C632).
• Lip pathology reports must be read carefully. If cancer site is stated to be in the vermillion of lip or mucosa of lip, code as follows:
  • Vermillion: upper lip (C000), lower lip (C001), or lip, NOS (C002)
  • Mucosa: mucosa upper (C003), mucosa lower (C004), mucosa NOS (C005)
• Anus pathology reports must be reviewed carefully. If cancer is stated to originate in anus, code site to anus, NOS (C210).

Reportability Examples:

1. 75-year-old male with penile skin lesion not responsive to topical treatment. Undergoes biopsy. Pathology- Penis Skin Biopsy: Well to moderately differentiated squamous cell carcinoma.
   • Reportable. Pathology and physical exam state the primary site is skin of the penis. Skin of penis is coded to C609 and is reportable.
2. 56-year-old female with concerning lump in left neck, parotid area. FNA cytology is positive for malignancy. Resection of parotid gland is performed. Pathology: Invasive 5.5 cm squamous cell carcinoma moderately differentiated. Records show history of cutaneous squamous cell carcinoma of the scalp. Physician confirms primary site is skin of scalp with metastasis to the parotid gland.
   • Not reportable. Although at first it appears that the squamous cell carcinoma originated in the parotid, the physician confirmed it is metastasis from a skin primary. Always look for clarification of primary site when a squamous cell carcinoma is in the parotid.
3. 68-year-old male with concerning area on skin of neck. Biopsy performed. Pathology: Skin with basal cell adenocarcinoma.
   • Reportable. Basal cell adenocarcinoma is coded to histology 8147/3 and is reportable for skin. Although basal cell adenocarcinoma is mostly found in the salivary glands, Cancer PathCHART confirms this is a valid combination. Do not interchange basal cell carcinoma with basal cell adenocarcinoma.

Bonus Tip-

NAACCR approved abbreviations for abstracts

• Squamous Cell Carcinoma – SCC or SQCC
• Squamous - SQ
• Basal Cell Carcinoma – BCC

Key Points:

• Read pathology thoroughly for primary site when histology is squamous cell carcinoma or basal cell carcinoma.
• Additional records can be used to supplement primary site information and contacting the physician may need to occur to determine correct site when reportability is in quesiton

References

SEER Manual: Reportability

https://seer.cancer.gov/tools/codingmanuals/

ICD-O-3

https://seer.cancer.gov/icd-o-3/

SEER Inquiry System

https://seer.cancer.gov/seer-inquiry/question Question ID 20230029, 20240030

NAACCR Abbreviations for Abstractors

https://apps.naaccr.org/data-dictionary/data-dictionary/version=26/chapter-view/abbreviations-and-acronyms/recommended-abbreviations-for-abstractors/

Cancer PathCHART

https://seer.cancer.gov/cancerpathchart/

SEER Solid Tumor Rules 2026

https://seer.cancer.gov/tools/solidtumor/

This month, we would like to share a reminder about Somatostatins. Somatostatin analogues (SSAs) are a human-made form of the natural hormone somatostatin. Somatostatins are not considered curative treatment but should be coded as hormone therapy when there is a physician statement saying these Somatostatin analogues are used to shrink, stop, or prohibit the growth of a tumor.

Names of Somatostatin Analogues (not a complete listing, see SEER*Rx for full list):

• Octreotide acetate (Sandostatin)
• Lanreotide (Somatuline)
• Pasireotide (Signifor)

Some instances when ODS would code Octreotide acetate (Sandostatin) as hormonal therapy (See SINQ 20250030):

• Code as hormonal therapy if given in SSTR2 positive meningioma (Per NCCN guidelines, 2025: smaller studies on meningiomas support the use of targeted therapy including somatostatin).
• Code as hormonal therapy if given in NETs (Per NCCN, for Tumor control: antitumor effect is supported by studies for G1/G2 gastro-entero-pancreatic NETs. In lung or thymic NETs somatostatin analogues may be used if metastases or SSTR are positive.)

Coding Examples

1. Patient diagnosed with a meningioma. Immunohistochemistry is SSTR2 positive. Somatostatin initiated followed by a gross total resection.
   • Hormone coded as 01 SSTR2 IHC was positive and somatostatin therapy was given.
2. Patient with12 mm lesion in the tail of pancreas on CT. Biopsy showed a well differentiated neuroendocrine tumor, WHO grade 2. Discussed Lanreotide therapy, patient elected not to pursue hormone therapy.
   • Hormone coded as 00. Discussion of Lanreotide therapy does not equal a recommendation.

Key Point:

Code octreotide acetate (Sandostatin) as hormonal therapy for certain tumors. SEER*RX has updated the entry for octreotide acetate because studies showed somatostatin analogs may shrink and/or prohibit further tumor growth. Somatostatin analogues are used to treat conditions such as acromegaly and NETs due to their longer half-life than the natural somatostatin hormone.

References:

SINQ

https://seer.cancer.gov/seer-inquiry/inquiry-search/?q=somatostatin+&date_modified=&date_modified=&o=table&d=question&d=discussion&d=answer&d=year

SEER Program Coding and Staging Manual

https://seer.cancer.gov/manuals/2025/SPCSM_2025_MainDoc.pdf

SEER*Rx Interactive Antineoplastic Drugs Database

https://seer.cancer.gov/seertools/seerrx/

Canswer Forum

https://cancerbulletin.facs.org/forums/search?q=sandostatin&searchJSON=%7B%22keywords%22%3A%22sandostatin%22%7D

This month, we are sharing a few tips on the 2025 Hematopoietic and Lymphoid Neoplasms updates regarding Human Herpes Virus 8 (HHV8)-positive Diffuse Large B-Cell Lymphoma (DLBCL) and Post Transplant Lymphoproliferative Disorder (PTLD).

HHV8-Positive DLBCL is a rare lymphoma and is known for arising in immunodeficient individuals, but it may occur in non-immunocompromised people as well. In 2021, HHV8-positive DLBCL was unintentionally made obsolete (see Revision History for the Hematopoietic Project > Revision History >2025 Changes). Even though this histology should have remained reportable, registrars are not required to search for missed cases but should collect and report any newly found cases.

PTLD is a new SSDI and arises in individuals who have undergone a solid organ transplant, allogeneic bone marrow transplant, or an umbilical cord blood transfusion. The patient must have a history of solid organ transplant or an allogenic bone marrow transplant to code this new SSDI. There are two types of PTLD, polymorphic and monomorphic, which are generated by post-transplant immunosuppression.

Coding Instruction Notes Summary (not a complete listing):

• Note 1: Effective years
  • This SSDI is effective for diagnosis years 2025 +
  • For years 2018-2024, this SSDI must be blank
• Note 2: Post Transplant Lymphoproliferative Disorder
  • The development of PTLD is clinically significant and a prognostic indicator.
• Note 3: Types of PTLD
  • Polymorphic PTLD: This is a PTLD by itself, there is no accompanying lymphoma, plasmacytoma or other type of Hematopoietic neoplasm. This type of PTLD is NOT collected in this data item.
    • Code as 9971/3 (Heme Retic Schema) (2025+ diagnoses only)
  • Monomorphic PTLD (Code 1): Most common PTLD, which is associated with malignant hematopoietic neoplasm. Most common, but not limited to, DLBCL and Burkitt lymphoma.
  • Classic Hodgkin lymphoma-PTLD type (Code 2): Under the microscope, Reed-Sternberg cells, which are associated with Hodgkin lymphoma are present.
  • PTLD, NOS (Code 4): Used when only PTLD (NOS) is documented and there is no mention of monomorphic or Hodgkin like type. Also used for Burkett-like PTLD.

Key Points:

• To code this new PTLD SSDI, the patient must have a history of solid organ transplant or an allogeneic bone marrow transplant. Otherwise, the SSDI should be blank.
• HHV8-positive DLBCL is reportable as histology 9738/3 and is to be collected for diagnosis year 2010 and forward.

Coding Examples:

1. Path report states “consistent with high grade B-cell lymphoma/Burkitt-like post-transplant lymphoproliferative disorder.”
   • Code histology to 9687 (high grade B-cell lymphoma/Burkitt-like PTLD). Per rule PH1, Hematopoietic and Lymphoid Neoplasm Coding Manual, version 3.3, page 58.
   • Code PTLD SSDI to 4 (includes Burkitt-type PTLD), per SSDI manual, version 3.2, page 447.
2. Patient with left cervical lymph node biopsy found to be malignant, CD30+. Diffuse large cell lymphoma, EBV +, diagnosis of PTLD, monomorphic type.  IgH and IgK : Not Detected.
   • Code histology to 9680/3 (per rules M14 and PH1, Hematopoietic and Lymphoid Neoplasm Coding Manual, version 3.3, pages 49 & 58).
   • Code PTLD SSDI to 1 (PTLD with a specified histology) per SSDI manual, version 3.2, page 447.

BONUS TIP:

For Hematopoietic Neoplasms ONLY, “Consistent with” is a definitive diagnosis and is not considered an ambiguous term.

References:

Revision History for the Hematopoietic Project

https://seer.cancer.gov/tools/heme/update.html

SSDI Manual

https://www.naaccr.org/wp-content/uploads/2025/11/Site-Specific-Data-Item-SSDI-Manual_v3.2_printed.pdf?v=1764769713

Hematopoietic and Lymphoid Neoplasm Coding Manual 2025

https://seer.cancer.gov/seertools/hemelymph/51f6cf56e3e27c3994bd5300/?q=hhv8-positive%20dlbcl

https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf

This month, Utah Cancer Registry shares a few reminders from the requirements for coding a simple prostatectomy versus a radical prostatectomy and how the different surgeries affect the extent of disease coding.

SURGERY CODING

According to the SEER site specific surgery codes for prostate, a subtotal, segmental, or simple prostatectomy is assigned code A300 and may leave all or part of the capsule intact.

A radical prostatectomy, also known as a total prostatectomy, is assigned code A500.  This procedure includes excision of the prostate, capsule, ejaculatory ducts, seminal vesicle(s); and may include a narrow cuff of bladder neck.

IMPORTANT: you must review the path report to determine which procedure was performed by looking at what tissue was removed. Do not rely on the title of the procedure or operative report to code the surgery field.

• Example 1: Operative report states prostatectomy was performed.

Pathology report-

Prostate Gland: Radical Prostatectomy.

CAP Protocol: Prostatectomy.

Gross: Prostatectomy specimen received in two pieces without lesions seen.

Surgery code = A300 (simple prostatectomy), no additional tissue submitted from outside the prostate gland in the pathology specimen. Even though the title of the procedure was stated to be radical prostatectomy, this does not meet the requirements to be coded to a radical prostatectomy.

• Example 2: Operative report states prostatectomy was performed.

Pathology report-

Prostate Gland: Radical Prostatectomy.

CAP Protocol: Prostatectomy.

Gross: Prostate with attached right and left seminal vesicles and vas deferens.

Surgery code = A500 (radical prostatectomy), seminal vesicles and vas deferens were removed which meet the definition of a radical prostatectomy.

EXTENT OF DISEASE (EOD) CODING

Histologic information from simple prostatectomies is used for clinical coding in the EOD Primary Tumor field.  Histologic information from radical prostatectomies is used for pathologic coding in the EOD Prostate Pathologic Extension field.

From the EOD Manual instructions for EOD Primary Tumor:

Note 1: EOD Primary Tumor field captures a clinical extent of disease only.

• Only use histologic information from a simple prostatectomy in this field.
• Do not record information from a simple prostatectomy in EOD Prostate Pathologic Extension.

From the EOD Manual instructions for EOD Prostate Pathologic Extension:

Note 1: Radical prostatectomy or autopsy results only.

• Only use histologic information from a radical prostatectomy and/or autopsy in this field.
• Information from simple prostatectomy, TURP, or biopsy of extraprostatic sites should be coded in EOD Primary Tumor.

Note 2: If no radical prostatectomy or autopsy, code 900.

• Example 1: Patient has a simple prostatectomy verified by the path report. No DRE, PSA, or extension documented.
  • EOD Primary Tumor = 300, localized, NOS. (Note 7: Code 300 for localized cancers when the DRE is not documented, or DRE not done and there is no clinical evidence of extraprostatic extension, or the physician incorporates imaging findings into their evaluation).
  • Prostate Pathological Extension = 900, no radical prostatectomy or autopsy performed.
• Example 2: Patient has a radical prostatectomy verified by the path report. No DRE or PSA documented. The radical prostatectomy pathology states tumor invades seminal vesicles with no other invasion identified.
  • EOD Primary Tumor = 300, (Note 7: Code 300 for localized cancers when the DRE is not documented, or DRE not done and there is no clinical evidence of extraprostatic extension, or the physician incorporates imaging findings into their evaluation).
  • Prostate Pathologic Extension = 400, tumor invades seminal vesicle(s).

Key Points:

• Operative and pathology reports, along with the coding rules and definitions must be read carefully to determine the best prostate surgery code to capture which procedure was actually completed.
• Simple prostatectomies are coded as clinical only in EOD Primary Tumor.
• Radical prostatectomies are coded as pathologic in Prostate Pathological Extension

BONUS TIP – Will only code clinical grades for simple prostatectomies. Gleason Pattern Pathologic, Gleason Score Pathologic and Gleason Tertiary Pattern will all be coded as X7- no radical prostatectomy performed.

References

SEER Manual:  Surgery of Primary Site coding instructions, and surgery codes in Appendix C –

https://seer.cancer.gov/tools/codingmanuals/

SEER Extent of Disease (EOD) 2018 for Prostate

https://seer.cancer.gov/tools/staging/eod/

Melanoma: Clinical Margin Width

The width of the clinical margin that surgeons take around a melanoma during the wide excision operation is based on how deeply the tumor invaded on the initial excision (Breslow depth); deeper tumors require wider margins. This SSDI became effective for the diagnosis years 2023 and forward. Cases diagnosed for the years 2018-2022 must be left blank.

Here are a few notes from the SSDI manual v3.2 (not a complete listing) regarding the Clinical Margin Width:

• “The appropriate [wide local excision] margins are measured from the periphery of any gross residual tumor or the edges of the entire previous biopsy scar (shave or excisional).”
• Pathology reports may not be used to code this data item.
• When multiple wide excisions have been performed, code the clinical margin width from the procedure with the largest margin.
• If a range is listed, the lower range should be coded.
  • Example: Clinical Width Margin documented as 1-1.3 cm. Code 1 cm
  • Make sure to record stated margin in centimeters

Coding Examples

1. Path report shows a shave biopsy diagnostic of superficial spreading melanoma. Breslow thickness 0.5mm, no ulceration present, mitotic activity is not present. A wide excision is performed and there is no residual melanoma. Path describes a 1cm margin from the previous scar. Operative report only documents wide excision.
   • Code the Clinical Margin Width as XX.9, the operative report does not mention a clinical margin width.
   • There is no Physician statement provided in this example. Per SSDI Note 4: Clinical margin width must come from the operative note or physician statement in medical records.
2. Path report shows shave biopsy diagnostic of a melanoma in situ arising from within a nevus. Lateral margin is involved. No mention of ulceration or mitotic activity. Re-excision is performed and no residual melanoma identified. Operative report text in abstract does not mention margins. The abstract text does document a physician statement of the clinical margin width being 6 mm.
   • Code the Clinical Margin Width as 0.6 cm. See SSDI Note 5, code formats-Record stated margin in centimeters.
   • SSDI Note 4, Physician statement- A physician statement of clinical margin width can be used to code this data item if no other information is available or if the information provided is ambiguous.
3. Path report shows a malignant melanoma with a Breslow’s depth of 1.7 mm and operative report states clinical margin is 1 to 1.2cm with dissection down to the muscularis fascia, abnormal tissue excised with grossly negative margins.
   • Code Clinical Margin Width as 1.0, because the clinical margin width was stated in the operative report. See SSDI Note 3, if a range is listed code the lower range.
   • SSDI Note 4: Clinical margin width must come from the operative note or physician statement in medical records.

Bonus Tip- “Per the American College of Surgeons Optimal Resources for Cancer Care-2020 Standards Standard 5.5 Local Excision for Primary Cutaneous Melanoma, the clinical margin width for wide local excision of invasive melanoma should be 1 cm for melanomas <1 mm thick, 1 to 2 cm for invasive melanomas 1 to 2 mm thick, and 2 cm for invasive melanomas >2 mm thick. The clinical margin width for wide local excision of a melanoma in situ should be at least 5 mm.”

Remember ODS must code what the operative report documents even if it doesn’t seem to fit the ACoS recommendations.

Key Points

• Clinical margin width should be stated in the op report or procedure notes; the path report may not be used.
• Moh's procedures are to be codded XX.9. We often see a clinical margin code other than XX>0 documented on Moh's procedures. See SSDI Note 5 Code Formats. Code XX.9 for Moh's or similar procedure.

References

SSDI Manual https://www.naaccr.org/wp-content/uploads/2024/10/Site-Specific-Data-Item-SSDI-Manual_v3.2_printed.pdf?v=1736344473

Related CAnswer Forum posts https://cancerbulletin.facs.org/forums/node/160243

https://cancerbulletin.facs.org/forums/node/152067#post168822

CODING THE MOST SPECIFIC HISTOLOGY

• Review the Coding Histology instructions for the specific STR module that applies to the case being abstracted; some contain subtle differences.  For example:
  • The Breast module does not state to always code the most specific histology; in most cases, subtypes/variants are only coded when documented to be greater than 90% of the tumor.
  • The Non-Malignant CNS module states that a more specific histology described as a “component” can be coded, whereas the Urinary module further specifies that a component must describe a carcinoma or sarcoma to be coded.
• Check the Priority Order for Using Documents to Identify Histology section of the appropriate STR module.  This reminds abstractors of various places to check for histology (including the CAP* synoptic section of pathology reports), and there may be differences between sites.
  • For example, the Malignant CNS module’s first priority for determining histology is biomarkers from the path report.

*CAP = College of American Pathologists

• Always work through the “H rules” for the site being abstracted; some contain exceptions relating to specific histologies in certain situations.  For example:
  • Lung rule H7 (two or more specific histologies), Note 3 - the histology pattern with the greatest percentage can be coded; this is an exception to the general instruction not to code histologies described as “pattern”.
  • Other Sites rule H15 (single subtype/variant), Note 3 – Refer to Tables 3-23, there may be exceptions to this rule.  One of these is in the Coding Notes at the beginning of Stomach Table 6:  Code the WHO Histology over a Lauren histology; Exception - code a more specific Lauren histology if the WHO histology is adenocarcinoma NOS.

Reminder -  all Solid Tumor modules contain an exception to the general rule that a post-neoadjuvant treatment histology shouldn’t be coded:  If the initial diagnosis is based on FNA, core biopsy, smears, cytology, OR is from a regional or metastatic site, and neoadjuvant treatment is followed by resection of the primary site, code histology from the primary site resection.  This exception is listed at the beginning of each module’s “Priority Order for Using Documents to Identify Histology” section.

CODING EXAMPLES

1. 3/1/2025 biopsy of a pancreatic mass showed adenocarcinoma.  3/23/2025 pancreatoduodenectomy pathology report, final diagnosis:  moderately differentiated adenocarcinoma, CAP synoptic section:  Histologic Type - Ductal adenocarcinoma.
   • Histology is coded 8500/3 - ductal adenocarcinoma, per rule H15 (NOS with a single subtype/variant), and its Note that directs us to Table 11.
   • See also Other Sites module, Coding Histology guidelines:  code the most specific histology; Priority Order section – path final diagnosis and CAP synoptic report have equal priority.

Bonus tip:  especially on melanoma path reports, the synoptic section may be the only place where a specific subtype is listed.

1. 10/5/2024 left breast core biopsy path:  invasive ductal carcinoma, grade 3.  Patient completes neoadjuvant treatment and the subsequent 12/20/2024 mastectomy path shows solid adenocarcinoma.
   • Histology is coded 8230/3 - solid adenocarcinoma, per rule H17 (only one histology present), and its Note 1 instructing to use Table 3.
   • The pre-treatment histology would be ignored, per the Exception in the “Priority Order for Using Documents to Identify Histology” section:  code the resection histology after neoadjuvant treatment, if histology was only from a core biopsy prior to treatment.  The Breast module clarifies that the general instruction where a subtype must comprise the majority of a breast tumor, does not apply because the majority histology cannot be determined from a core biopsy.

1. After an addendum for gene panel testing, pathology from a 1/12/2025 cerebellar tumor resection returns as medulloblastoma, classic histologic type, non-WNT/non-SHH molecular group.
   • Histology is coded 9477/3 - Medulloblastoma non-WNT/non-SHH, per rule H4 (NOS with a single subtype/variant), and its Note 2 stating to see Table 3.
   • See also the source priority order for histology in the Malignant CNS module; biomarkers take priority over other information on the pathology report, and include genetic testing, FISH, and MYCN.
   • WNT and SHH are genetic markers in medulloblastomas.

KEY POINT: 

While the solid Tumor Rules generally instruct abstractors to code the most specific histology, it is crucial to review instructions for each specific site being abstracted. These contain guidance unique to that type of cancer, and also list important reminders about priority of sources and potential exceptions to the rules.

References

SEER Solid Tumor Rules manual - https://seer.cancer.gov/tools/solidtumor/

Related SEER Inquiry System topics (SINQs):

Histologic components in Urinary tumors - https://seer.cancer.gov/seer-inquiry/inquiry-detail/20220035/

Interpreting Histologic Type/majority in CAP synoptic section of breast path reports - https://seer.cancer.gov/seer-inquiry/inquiry-detail/20180045/

NET:  Ki-67 tumor marker

Neuroendocrine Tumors (NETs) have a SSDI (Site-Specific Data Item) called Ki-67 which is a marker for cell proliferation, and when the value is high it means the tumor is proliferating more expeditiously.

Here are a few notes (not a complete listing) from the SSDI Manual regarding the Ki-67 tumor marker:

• A physician statement can be used to code Ki-67 when no other information is available.
• A specified value takes precedence over the range value codes XXX.4, XXX.5 and XXX.6.  One must code the exact percentage when it is provided.
• We cannot use results from nodal or metastatic sites and must code XXX.9 in these situations.
• This data item should be recorded prior to neoadjuvant treatment; however, if there are no results from pre-treatment specimens, coding results from post-treatment specimens is permitted.

Be aware of alternate names so Ki-67 is not overlooked when coding this tumor marker. Here are a couple of the other names:

• Proliferation index
• MIB-1 (shows the number of cells within a tissue sample that are actively dividing).

GIST:  KIT Gene Immunochemistry tumor marker

In Gastrointestinal Stromal Tumors (GISTs), the KIT gene regulates and controls cell growth and differentiation. This immunochemistry stain confirms the diagnosis of GIST; it is also helpful in predicting if the patient may respond to systemic treatments, such as imatinib or sunitinib.

Coding Instructions from the SSDI manual:

• A physician statement can be used to code KIT IHC results when no other information is available.
• Nodal or metastatic tissue results may be used for KIT Gene immunohistochemistry [unlike the Ki-67 tumor marker].

It’s important to be aware of alternate names so this SSDI is not overlooked. Here are a few of the other names, which may be listed among other IHC stains on the path report:

• CD117
• C-kit receptor
• KIT receptor kinase
• Stem cell factor receptor (SCFR)

CODING EXAMPLES

1. Path report shows a 2.0 cm mass in the ileum, Grade 2 well differentiated neuroendocrine tumor, with a proliferation index of 3.2%. Also noted to have a 6 cm tumor in the mesentery with a Ki-67 higher than 16%.
   • Code the Ki-67 SSDI as 2; proliferation index is another name for Ki-67.
   • In the SSDI Manual, Note 4 instructs us that we cannot use results from nodal or metastatic tissue for Ki-67. We would ignore the mesenteric tumor results, even though they’re higher.
2. CT A/P shows a 9.2 cm mass arising from the small bowel. MRI of abdomen reveals numerous small foci in the liver favoring mets. Liver biopsy pathology is diagnostic of metastatic GIST, spindle cell type.  Immunohistochemical stains are positive for CD34, CD117, and DOG1 but negative for CD3, CD20, langerin, and CD68.
   • Code the KIT SSDI as 1 (positive); CD117 is another name for KIT.
   • SSDI Note 2 says we can use nodal or metastatic tissue to code KIT gene immunohistochemistry, so the liver biopsy results are acceptable.
3. Resection of a duodenal GIST returned c-Kit staining as weakly positive; biopsy of a distant lymph node showed negative c-Kit; path comment:  c-Kit can be negative in high-grade GISTs.
   • Code KIT as 1 (positive).  c-Kit is an alternate name for KIT.
   • Per SSDI general instructions for Recording Tests Based on Solid Tissues, record the highest value from any tissue-based examination.  CAnswer Forum confirms that even “weakly positive” should be coded over a negative KIT result (see References, below).

Bonus Tips (from CAnswer Forum, see References section below)

• KIT must be from IHC testing, not DNA mutation sequencing.
• In the Ki-67 SSDI, the range codes (XXX.4, XXX.5, XXX.6) apply to any non-specific value that falls into that range; for example, “Ki-67: 1-2%” is coded XXX.4 (less than 3%), and “5-7%” is coded XXX.5 (3-20%).

Key Points

• Carefully check the specific guidelines for various tumor markers in the SSDI Manual; some SSDIs allow coding from metastatic or post-neoadjuvant tissue, and others do not.
• Become familiar with alternate names for tumor markers that are listed in the SSDI Manual.
• If a certain coding situation is not addressed in the specific guidelines for a particular SSDI, check the applicable section in the General Definitions and Rules, near the beginning of the SSDI Manual.

References

SSDI Manual, https://www.naaccr.org/wp-content/uploads/2024/10/Site-Specific-Data-Item-SSDI-Manual_v3.2_printed.pdf?v=1736344473

Related CAnswer Forum posts

• KIT from DNA sequencing results,   https://cancerbulletin.facs.org/forums/node/137014?p=151781#post151781
• Ki-67 range codes, https://cancerbulletin.facs.org/forums/node/130483
• Highest KIT result from primary vs. mets tissue, https://cancerbulletin.facs.org/forums/node/127552
• Confirmation that post-neoadjuvant Ki-67 can be coded if no pre-treatment testing was done, https://cancerbulletin.facs.org/forums/node/166894#post166909

This month, Utah Cancer Registry shares a few reminders about coding some of the breast data items when tests are done on unusual specimens, such as nodal or metastatic tissue, or with results from multiple specimens.

Grade items

Per Table 12 (Breast) coding notes in the Grade Manual, grade from regional lymph node tissue may be used ONLY when there was never any evidence of a primary tumor (T0).

• In this situation, grade would be coded using G1, G2, or G3 - even if the grading is not strictly Nottingham, which is difficult to perform in nodal tissue.
• This is a rare exception to the general rule that “differentiation” terminology is converted to alpha codes when those are available in the schema.  For these types of breast cases, numeric codes are assigned.
  • For example, a T0 tumor with grade from nodal tissue that’s stated as “well differentiated” would be assigned code 1 (not A), moderately differentiated would be code 2 (not B), etc.

Reminder: grade from metastatic tissue other than regional lymph nodes is never used, even in T0 tumors; code 9 for these cases if the only grade available is from a non-nodal metastatic site.

Site-Specific Data Items (SSDIs)

For Estrogen Receptor Summary, Progesterone Receptor Summary, and HER2 Overall Summary:

• Results from nodal or metastatic tissue may be used ONLY when there is no evidence of any primary tumor (including no in situ tumor).
• Unlike Grade, ER/PR/HER2 can be coded from metastatic tissue (such as a biopsy of bone metastasis), if there is NO evidence of a primary tumor.
• Results from tests done on multiple specimens:
  • If all tests are from a single tumor, use the highest result (positive versus negative).
  • If tests are done on multiple tumors, use the results from the largest tumor size, determined either clinically or pathologically (be careful not to confuse this with the path specimen size).

CODING EXAMPLES (note:  for brevity, these examples do not address the various timeframes for grade items – clinical vs. pathological, etc.  Instructions for determining the appropriate grade items/timeframes can be found in the Grade Manual and AJCC resources).

1. 10/16/2024 left breast lumpectomy pathology report, final diagnosis: invasive carcinomas including NST (ductal) type, grade 3, approximately 12 mm; and invasive lobular carcinoma, grade 2, at least 20 mm.  The CAP synoptic section only addresses the lobular carcinoma, Special Studies: Estrogen Receptor positive, Progesterone Receptor positive, HER2 negative.  Path comment: The invasive ductal carcinoma receptors are ER negative, PR weak positive (5%), and HER2 negative.
   • Per breast Solid Tumor Rules M10 and H28, this is a single primary, mixed ductal & lobular histology 8522/3.
   • Grade is coded 3 from the NST/ductal tumor, as the highest grade from multiple tumors (see Grade Manual, Item-Specific Data Dictionary and Coding Guidelines section).
   • ER, PR, and HER2 SSDIs are all coded from the largest tumor (the lobular carcinoma) – ER Summary = 1, PR Summary = 1, HER2 Overall Summary = 0. 

1. Patient presents with abdominal pain and distention, 10/30/2024 imaging finds large volume ascites of uncertain cause, no visible peritoneal or omental caking.  Paracentesis cytology shows poorly differentiated adenocarcinoma, consistent with metastatic lobular breast carcinoma; ER positive, PR positive, and HER2 negative.  Physical exam, mammogram and ultrasound of breasts were all negative for masses.  Palliative Ibrance and letrozole are started in December 2025.
   • Grade is coded 9, even though the cytology stated poorly differentiated; grade from a metastatic site is never coded.
   • Tumor marker SSDIs can be coded from the paracentesis, only because there is no evidence of a primary tumor in this case – ER Summary = 1, PR Summary = 1, HER2 Overall Summary = 0.

1. 3/20/2025 right axillary lymph node biopsy, path final diagnosis:  invasive mammary carcinoma of no special type, Nottingham grade 3; ER positive, PR positive, HER2-NEU negative; the primary tumor was not biopsied.  4/7/2025 left breast mastectomy, path final diagnosis:  invasive ductal carcinoma, histologic grade 2 (score 3+2+2=7/9); comment – Breast biomarker studies performed on previous left axillary mass biopsy showed ER/PR positive, HER2 negative.  No evidence that receptor testing was repeated on the mastectomy specimen.
   • Grade is coded 2 from the primary tumor specimen in the mastectomy, even though it is lower than that assigned to the lymph node metastasis.  Grade from lymph nodes is only coded in breast cases when there is NO evidence of a primary tumor.
   • ER, PR and HER2 SSDIs are all coded as Unknown (9), since results from lymph node tissue can only be used if there is NO evidence of a primary tumor.

KEY POINT:  Because it is unusual for Grade or SSDI testing to be done on non-primary tumor tissue or multiple tumor specimens, it’s important to review the unique coding guidelines in the appropriate manuals when these cases come up.

References

Grade Manual, Table 12 (breast) and its Coding Notes - https://www.naaccr.org/wp-content/uploads/2024/10/Grade-Coding-Instructions-and-Tables-v3.2_printed.pdf?v=1752244511

SSDI Manual, schema 00480 (breast), ER/PR/HER2 Summary items and their Coding Notes - https://www.naaccr.org/wp-content/uploads/2024/10/Site-Specific-Data-Item-SSDI-Manual_v3.2_printed.pdf?v=1752244511

Solid Tumor Manual, Breast module - https://seer.cancer.gov/tools/solidtumor/current/STM_Combined.pdf

CAnswer Forum post confirming that Grade and tumor markers can be coded from different tumors abstracted as a single primary (as in Coding Example 1 above) - https://cancerbulletin.facs.org/forums/node/133366?p=145581#post145581