For solid tumors only (histologies other than 9590-9992), this is a hierarchical schema to identify how the malignancy was determined - from histologic confirmation (1) being most precise to unknown (9) being the least. Lower numbered codes take precedence over higher numbered codes. The code must be changed to a lower code if a more definitive method confirms the diagnosis at any time during the course of the disease. Code 3 in the table below does NOT apply to solid tumors.
Separate rules were established for non-solid tumors (histology codes 9590-9992) in 2010. Prior to that, registrars were instructed to use Code 1 for positive hematologic findings and bone marrow specimens for leukemia, including peripheral blood smears and aspiration biopsies. Otherwise, to use Code 2 for positive brushings, washings, cell aspiration, and hematologic findings (except for leukemia).
For non-solid tumors (histology codes 9590-9992) beginning in 2010, the table below is NOT hierachical, and the rules for assignment are specific to non-solid tumors.
Coding Instructions for All Tumors
- Assign Code 1 when the microscopic diagnosis is based on tissue specimens from biopsy, frozen section, surgery, autopsy, D&C or from aspiration or biopsy of bone marrow specimens.
- Assign Code 2 when the microscopic diagnosis is based on cytologic examination of cells such as sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, pleural fluid, urinary sediment, cervical or vaginal smears, or from paraffin block speciments from concentrated spinal, pleural or peritoneal fluid. These methods are rarely used for hematopoietic or lymphoid tumors.
- Assign Code 5 when the diagnosis of cancer is based on laboratory tests or marker studies which are clinically diagnostic for that cancer.
- Assign Code 6 when the diagnosis is based only on the surgeon's operative report or from a surgical exploration or endoscopy or from gross autopsy findings in the absence of tissue or cytologic findings.
Additional Coding Instructions for Hematopoietic or Lymphoid Tumors (Histologies 9590-9992)
- There is no priority hierachy for coding Diagnostic Confirmation for hematopoietic and lymphoid tumors. Most commonly, the specific histologic type is diagnosed by immunophenotypoing or genetic testing. See the Hematopoietic Database (DB) for information on the definitive diagnostic confirmation for specific tumors.
- For leukemia only, assign Code 1 when the diagnosis is based only on the complete blood count (CBC), white blood count (WBC) or peripheral blood smear. Do not use Code 1 if the diagnosis was based on immunophenotyping or genetic testing using tissue, bone marrow, or blood.
- Assign Code 3 when there is a histologic positive for cancer AND positive immuniphenotyping and/or postiive genetic testing results. Do not use Code 3 for neoplasms diagnosed prior to January 1, 2010.
- Assign Code 8 when the case was diagnosed by any clinical method that can not be coded as 6 or 7. A number of hematopoietic and lymphoid neoplasms are dignosed by tests of exclusion where the tests for the disease are equivocal and the physician makes a clinical diagnosis based on the information from the equivocal tests and the patient's clinical presentation.
- Assign Code 6 when the diagnosis is based only on the surgeon's operative report from a surgical exploration or endocscopy or from gross autopsy findings in the absence of tissue or cytologic findings.
- Assign Code 1 when microscopic diagnosis is based on tissue specimens from biopsy, frozen section, surgery, autopsy or D&C or from aspiration of biopsy bone marrow specimens.
- Assign Code 2 when microscopic diagnosis is based on cytologic examination of cells such as sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, peritoneal fluid, urinary sediment, or peritoneal fluid. These methods are rarely used for hematopoietic or lymphoid cancers.
- Assign Code 5 when the diagnosis of cancer is based on laboratory tests or marker studies which are clinically diagnostic for that specific cancer.
In 2010, cancer registries in North America adopted new rules for coding hematopoietic and lymphoid tumors. At that time, this item was modified for cases diagnosed in 2010 or later to better reflect the ways these tumors are diagnosed. Code 3 was defined and implemented at that time, and the rules for coding were refined. The instructions and table presented here represent a combination of the new instructions and the older instructions that still apply to solid tumors.
|1||Positive histology||Histologic confirmation (tissue microscopically examined)|
|2||Positive cytology||Cytologic confirmation (no tissue microscopically examined; fluid cells microscopically examined|
|3||Postive histology PLUS positive immunophenotyping and/or positive genetic studies||Histology is positive for cancer, and there are also positive immunophenotyping and/or genetic test results. Use this code only for histology range 9590-9992 where the year of diagnosis is 2010 or later|
|4||Positive microscopic confirmation, method not specified||Microscopic confirmation is all that is known. It is unknown if the cells were from histology or cytology|
|5||Positive laboratory test/marker study||A clinical diagnosis of cancer is based on laboratory tests/marker studies which are clinically diagnostic for cancer. This includes alpha-fetoprotein for liver cancer and abnormal electrophoretic spike for multiple myeloma. Elevated PSA is nondiagnostic of cancer. If the physician uses the PSA as a basis for diagnosing prostate cancer with no other workup, record as code 5. (Adapted from SEER.)|
|6||Direct visualization without microscopic confirmation||The tumor was visualized during a surgical/endoscopic procedure only with no tissue resected for microscopic examination|
|7||Radiography and other imaging techniques without microscopic confirmation||The malignancy was reported by the physician from an imaging technique report only|
|8||Clinical diagnosis only (other than 5, 6, or 7)||The malignancy was reported by the physician in the medical record|
|9||Unknown whether or not microscopically confirmed||A statement of malignancy was reported in the medical record, but there is no statement of how the cancer was diagnosed (usually Class of Case 3)|