1 head and neck mp/h task force multiple primary rules histology coding rules 2007

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Head and Neck

MP/H Task Force

Multiple Primary Rules

Histology Coding Rules

2007

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Equivalent Terms, Definitions, Charts, Tables and Illustrations

• Primary site– Do not code biopsy site

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Priority Order Code Primary Site

1. Tumor Boarda. Specialty

b. General

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2. Staging physician’s site assignmenta. AJCC staging form

b. TNM statement in medical record

If neither 1 or 2 available, based on whether tumor was resected

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3. Total resection of primary tumor (margins may be microscopically positive)a. Operative report – surgeon’s statement

b. Final diagnosis on pathology report

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4. No resection (may have biopsy)a. Endoscopy

b. Radiation oncologist

c. Diagnosing physician

d. Primary care physician

Continued on next slide

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e. Other physician

f. Diagnostic imaging

g. Physician statement based on clinical examination

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Default Site Codes

• Point of origin cannot be determined– C02.8 Overlapping lesion of tongue– C08.8 Overlapping lesion of major salivary

glands– C14.8 Overlapping lesion of lip, oral cavity,

and pharynx.

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Column 1: Paired Sites

Column 2:Code

Parotid Glands C079

Major Salivary Glands C080; C081

Tonsils C090; C091; C098; C099

Nasal Cavity C300

Accessory Sinuses C310; C312

Middle Ear C301

Table 1 – Paired Sites

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Chart 1 – H&N Histology Groups and Specific Types

Use this chart with the histology rules to code the most specific histologic term. The tree is arranged in descending order. Each branch is a histology group, starting with the NOS or group terms and descending into the specific types for that group. As you follow the branch down, the terms become more specific

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Papillary carcinom a (8050)Verrucous carcinom a (8051)Papillary squam ous cell carcinom a; Papillary

epiderm oid carcinom a (8052)

Large cell keratinizing; Keratinizing NOS (8071) Large cell nonkeratinizing;Nonkeratinizing

squam ous cell carcinom a, NOS (8072) Sm all cell nonkeratinizing squam ous cell carcinom a (8073)Sarcom atoid; Spindle cell squam ous cell

carcinom a (8074)Acantholytic; Adenoid; Pseudoglandular

squam ous cell carcinom a (8075)Squam ous cell carcinom a w ith horn

form ation (8078)

Lym phoepithelial carcinom a;Schm incke tum or (8082)

Basaloid squam ous cell carcinom a (8083) Clear cell type squam ous cell carcinom a (8084)

Squam ous Carcinom a(8070)

Adenocarcinom a, NOS(8140)

Cancer/ MalignantNeoplasm (8000-8001),

Carcinom a, NOS(8010)

Mucoepiderm oidcarcinom a (8430)

Acinar carcinom a(8550)

Adenocarcinom aw ith m ixed subtypes

(8255)

Adenocysticcarcinom a (8200)

Adenosquam ous(8560)

UndifferentiatedCarcinom a (8020)

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MP/H Task Force



2007

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Unknown if Single or Multiple Tumors

MP/H Task Force



2007

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HEAD AND NECK

M1Is it impossible to de termine if

there is a single tumor or multipletumors?

NOT ESDECISION

NO

YES

UNKNOWN IF S INGLE OR M ULT IPLET UM ORS

Use this rule only afte r all information sources havebeen exhausted.

Example 1: His tory and phys ical exam s tates largetum or in nasopharynx. B iopsy base of tongue show ssquam ous cell carc inom a. No further inform ation available.Abs trac t as a s ingle prim ary.

Example 2: Pathology report s tates extens ivesquam ous cell carc inom a involving nasopharynx and larynx.Fragm ents of epiglottis pos itive for squam ous cellcarc inom a. No other inform ation available. Abs trac t as as ingle prim ary.

T umor(s) not described as metastasis.

G o to Single T umoror M ultiple T umors

End of instruc tionsfor Unknown if S ingleor Multiple Tumors

SING LEPrimary*

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Single Tumor

MP/H Task Force



2007

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Is there a single tumor?

NO

M2 T he tumor may overlap onto or extend intoadjacent/contiguous site or subsite .

SINGLE T UM OR

YES

NOT ES

G o to M ultipleT umors.

SING LEPrimary*

DECISION

End of instruc tionsfor S ingle Tumor.

1. T umor not described as metastasis.2. Includes combinations of in situ and invasive

HEAD AND NECK

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Multiple Tumors

MP/H Task Force



2007

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NOT ESDECISIONM ULT IPLE T UM ORS

YES

NO

Are there tumors in both the le ftand right sides of a paired site ?

M3

Multiple tumors may be a singleprimary or multiple primaries.

1. T umors not described as metastases.2. Includes combinations of in situ and invasive .

M ULT IPLEPrimaries**

HEAD AND NECK

See T able 1 for list of paired sites.

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YES

NO

M4


Are there tumors on the upper lip(C000 or C003) and the lower lip

(C001 or C004)?



HEAD AND NECK

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M5



Are there tumors on the upper gum(C030) and the lower gum (C031)?

YES

NO


HEAD AND NECK

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M6

Are there tumors in the nasal c avity(C300) and the middle ear (C301)?


NO

YES

HEAD AND NECK

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YES

NO

M7

NOT ESDECISIONM ULT IPLE T UM ORS, continued


1. T umors not de scribed as metastases.2. Include s combinations of in situ and invasiv e .

Are there tumors in site s with ICD-O -3topography codes that are diffe re nt at the

second (Cxxx) and/or third characte r

(Cxxx)?

HEAD AND NECK

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YES

NOM8

Is the re an invasive tumor

following an in situ tumormore than 60 days afte r

diagnosis?

1. T he purpose of this rule is to ensure that thecase is counted as an incident (inv asive ) casewhe n incide nce data are analyzed.

2. Abstract as multiple primarie s ev en if theme dical record/physician states it is recurrenceor progression of disease .

NO



1. T umors not de scribed as metastases.2. Include s combinations of in situ and invasiv e .

HEAD AND NECK

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YES

NO

M9




Are tumors diagnosed more than five (5)years apart?

HEAD AND NECK

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NOT ESDECISIONM ULT IPLE T UM ORS, continued1. T umors not described as metastases.2. Includes combinations of in situ andinvasive .

NO

HEAD AND NECK

M10

NO

YESIs there cancer/malignant neoplasm, NO S(8000) and another is a specific histology?

Is there carcinoma, NO S (8010) andanother is a specific carcinoma?

Is there adenocarcinoma, NO S (8140) andanother is a specific adenocarcinoma?

Is there sarcoma, NO S (8800) andanother is a specific sarcoma?

YES

YES

NO

NO

SING LEPrimary*

Is there me lanoma, NO S (8720) andanother is a specific me lanoma?

Is there squamous ce ll carcinoma, NO S (8070) andanother is a specific squamous ce ll carcinoma?

NO

NO

NO

NO

YES

YES

YES

NO

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Do the tumors have ICD-O -3 histologycodes that are diff erent at the first (xxxx),

second (xxxx) or third (xxxx) number?

M11


YES M ULT IPLEPrimaries**

NO

T umors not described as metastases.

HEAD AND NECK

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Does not meet any of theabove criteria

(M 1 through M 11).

M12


YES 1. When an invasive tumor follows an in situtumor within 60 days, abstract as a singleprimary.

SING LEPrimary*

NO

ERRO R: Recheck rules.Stop when a match is found.

End of instruc tionsfor Multiple Tumors.

2. All cases covered by Rule 12 havethis ruleare the same histology.

T umors not described as metastases.

Rule M 12 Examples: T he following are examples of cases that use Rule M 12. T his is NO T intended to be an exhaustive se t of examples;there are other cases that may be classified as a single primary.Warning: Using only these case examples to de termine the number of primaries can result in major e rrors.

Exam ple 1. Multifocal tum ors in floor of m outh Exam ple 2. An in s itu and invas ive tum ordiagnosed w ithin 60 days

Exam ple 3. In s itu follow ing an invas ive tum orm ore than 60 days apart

HEAD AND NECK

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Histology Rules

MP/H Task Force



2007

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Single Tumor

MP/H Task Force



2007

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YESH1

NO

Is there nopathology/c ytology

specimen or is thepathology/c ytology report

unavailable?

1. Priority for using documents to code the histologyDocumentation in the medical record that re fe rs to pathologicor cytologic findingsPhysician's re fe rence to type of cancer (histology) in themedical recordCT , PET or M RI scans

2. Code the specific histology when documented.

3. Code the histology to 8000 (cancer/malignant neoplasm, NO S)or 8010 (carcinoma, NO S) as stated by the physician whennothing more specific is documented.

Rule Action Notes and Examples

Code thehistology

documentedby the

physician.

HEAD AND NECK

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H2

Is the specimen from ametastatic site?

(there is no pathology/cytologyspecimen from the primary site )

Code the behav ior /3.

NO

YES


Code thehistology from ametastatic site .

HEAD AND NECK

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Is only one histologictype identified?

NO

H3

YES


Code thehistology.

HEAD AND NECK

Example: Squamous cell carcinoma. Code 8070.

Do not code te rms that do not appear in the histology description.

Example: Do not code 8072 (squamous ce ll caricnomanon-keratiniz ing) unless the words "non-keratiniz ing" actuallyappear in the diagnosis.

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Does the tumor have invasiveand in situ components?

H4

YES

NO

Code theinvasive

histology.

E xample: T he final diagnosis is keratiniz ing squamous ce llcarcinoma (8073) with areas of squamous ce ll carcinoma in situ(8070). Code the invasive histologic type , keratiniz ing squamousce ll carcinoma (8073).

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H5

Rule A ction Notes and Examples

1. T he specific histology for in situ tumors may be identifiedas patte rn, architecture , type , subtype , predominantly, withfeatures of, major, or with ______ diffe rentiation.

2. T he specific histology for invasive tumors may beidentified as type , subtype , predominantly, with features of,major, or with ______ diffe rentiation.

Are there multiple histologies within the samebranch such as:

cancer/malignant neoplasm, NO S (8000) anda more specific histology? O Rcarcinoma, NO S (8010) and a more specificcarcinoma? O Rsquamous ce ll carcinoma, NO S (8070) and amore specific squamous ce ll carcinoma? O Radenocarcinoma, NO S (8140) and a more

specific adenocarcinoma? O Rmelanoma, NO S (8720) and a more specificmelanoma? O Rsarcoma, NO S (8800) and a more specificsarcoma?

Code themost

spec ifi chistologicte rm using

Chart 1

Example: T he final diagnosis is squamous ce llcarcinoma (8070), papillary (8050). Code the specific type ,papillary (8050)

H6

This is the end of ins truc tions for S ingle Tum or.C ode the his tology according to the rule that fits the case.

Code thenumeric ally

higherICD-O -3

histology code .

Ye s

NO

HEAD AND NECK

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Multiple Tumors Abstracted as a Single Primary

MP/H Task Force



2007

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YESH7

NO

Is there no

pathology/c ytology specimen

or is the pathology/c ytologyreport unavailable?


Code thehistology

documentedby the

physician.

1. Priority for using documents to code the histologyDocumentation in the medical record that re fe rs to pathologicor cytologic findingsPhysician's re fe rence to type of cancer (histology) in themedical recordCT , PET or M RI scans

2. Code the specific histology when documented.

3. Code the histology to 8000 (cancer/malignant neoplasm, NO S)or 8010 (carcinoma, NO S) as stated by the physician whennothing more specific is documented.

HEAD AND NECK

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H8 Is the specimen from ametastatic site

(there is no pathology/cytologyspecimen from the primary site?

Code the behav ior /3.

NO

YES


Code thehistology from

a metastaticsite .

HEAD AND NECK

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HEAD AND NECK

Is only one histologic typeidentified?

NO

H9YES

Code thehistology .

E xample: Squamous cell carcinoma. Code 8070.

Do not code te rms that do not appear in the histology description.

Example: Do not code 8072 (squamous ce ll caricnomanon-keratiniz ing) unless the words "non-keratiniz ing" actuallyappear in the diagnosis.

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H10

1. See the Head and Neck Equivalent T erms, Definitions,Charts, T ables and Illustrations for the de finition of mostinvasive .

O ne tumor is in situ and one is invasive , code thehistology from the invasive tumor.Both/all histologies are invasive , code thehistology of the most invasive tumor.

Code thehistology ofthe most

invasivetumor.

Is one tumor in situ and theother invasive

or are both tumors invasive?

YES

NO

2. If tumors are equally invasive , go to the next rule .

HEAD AND NECK

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H11

Rule A ction Notes and Examples

1. T he specific histology for in situ tumors may be identifiedas patte rn, architecture , type , subtype , predominantly, withfeatures of, major, or with ______ diffe rentiation.

2. T he specific histology for invasive tumors may beidentified as type , subtype , predominantly, with features of,major, or with ______ diffe rentiation.

Are there multiple histologies within the samebranch such as:

cancer/malignant neoplasm, NO S (8000) anda more specific histology? O Rcarcinoma, NO S (8010) and a more specificcarcinoma? O Rsquamous ce ll carcinoma, NO S (8070) and amore specific squamous ce ll carcinoma? O Radenocarcinoma, NO S (8140) and a more

specific adenocarcinoma? O Rmelanoma, NO S (8720) and a more specificmelanoma? O Rsarcoma, NO S (8800) and a more specificsarcoma?

Code themost

spec ifi chistologicte rm using

Chart 1

Example: T he final diagnosis is squamous ce llcarcinoma (8070), papillary (8050). Code the specific type ,papillary (8050)

H12

This is the end of ins truc tions for Multiple Tum ors Abs trac ted as a S ingle P rim ary.C ode the his tology ac c ording to the rule that fits the c as e.

Code thenumeric ally

higherICD-O -3

histology code .

Ye s

NO

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MP/H Task Force

1 head and neck mp/h task force multiple primary rules histology coding rules 2007

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