1 head and neck. 2 equivalent terms, definitions, charts, tables and illustrations primary site...
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Head and Neck
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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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Priority Order Code Primary Site
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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Priority Order Code Primary Site
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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Priority Order Code Primary Site
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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Priority Order Code Primary Site
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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Multiple Primary Rules
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Unknown if Single or Multiple Tumors
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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
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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
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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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NOT ESDECISIONM ULT IPLE T UM ORS
YES
NO
M4
M ULT IPLEPrimaries**
Are there tumors on the upper lip(C000 or C003) and the lower lip
(C001 or C004)?
Multiple tumors may be a singleprimary or multiple primaries.
1. T umors not described as metastases.2. Includes combinations of in situ and invasive .
HEAD AND NECK
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NOT ESDECISIONM ULT IPLE T UM ORS
M5
Multiple tumors may be a singleprimary or multiple primaries.
1. T umors not described as metastases.2. Includes combinations of in situ and invasive .
Are there tumors on the upper gum(C030) and the lower gum (C031)?
YES
NO
M ULT IPLEPrimaries**
HEAD AND NECK
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NOT ESDECISIONM ULT IPLE T UM ORS
Multiple tumors may be a singleprimary or multiple primaries.
1. T umors not described as metastases.2. Includes combinations of in situ and invasive .
M6
Are there tumors in the nasal c avity(C300) and the middle ear (C301)?
M ULT IPLEPrimaries**
NO
YES
HEAD AND NECK
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YES
NO
M7
NOT ESDECISIONM ULT IPLE T UM ORS, continued
M ULT IPLEPrimaries**
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
NOT ESDECISIONM ULT IPLE T UM ORS, continued
M ULT IPLEPrimaries**
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
NOT ESDECISIONM ULT IPLE T UM ORS, continued
M ULT IPLEPrimaries**
1. T umors not described as metastases.2. Includes combinations of in situ and invasive .
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
NOT ESDECISIONM ULT IPLE T UM ORS, continued
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
NOT ESDECISIONM ULT IPLE T UM ORS, continued
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
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Single Tumor
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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
Rule Action Notes and Examples
Code thehistology from ametastatic site .
HEAD AND NECK
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Is only one histologictype identified?
NO
H3
YES
Rule Action Notes and Examples
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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Rule Action Notes and Examples
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
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YESH7
NO
Is there no
pathology/c ytology specimen
or is the pathology/c ytologyreport unavailable?
Rule Action Notes and Examples
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
Rule Action Notes and Examples
Code thehistology from
a metastaticsite .
HEAD AND NECK
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Rule Action Notes and Examples
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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Rule Action Notes and Examples
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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