QC Corner – Questions, Answers, and Clarifications
ABSTRACTOR QUESTIONS FROM QC
Tumor Note: EITHER DIAGNOSTIC CONFIRMATION IS 1, OR HISTOLOGY IS CARCINOMA NOS BASED ON RADIOLOGY.
FACILITY RESPONSE: STEVE PEACE ADVISED SINCE 98% OF PROSTATE CANCER IS ADENOCARCINOMA TO CODE IT TO 8140/3 RATHER THAN CARCINOMA NOS., WE CAN CHANGE IT TO 8010/3 IF THAT IS HOW YOU WANT TO HANDLE CLINICAL PROSTATE CASES NOW. PLEASE ADVISE.
Answer: If the diagnosis is based on imaging, the diagnostic confirmation should be coded to 7, and histology would reflect 8000 for malignancy. Assign a diagnostic confirmation to code 1 and histology to 8140 when there is a biopsy and histology agree with pathologic findings of adenocarcinoma.
I HAVE A QUESTION REGARDING TEXT DOCUMENTATION. FOR ANY PALLIATIVE CARE RECOMMENDED, WHERE SHOULD TEXT INFORMATION BE DOCUMENTED IN THE ABSTRACT? SHOULD WE DOCUMENT INFORMATION IN THE OTHER TREATMENT OR PHYSICAL EXAM TEXT FIELD? ALSO, WHERE SHOULD WE TEXT GENERAL TREATMENT REFUSAL WHEN THEY DON’T WANT TO GET ANY FURTHER WORK-UP?
Answer: Document palliative care in the physical exam or under the Other Treatment text field.
Any treatment that was not performed and was recommended by the patient’s physician but refused by the patient, a family member, or a guardian. Assign Code 7 for Reason No Therapy.
If the patient refused recommended surgery, radiation therapy, and systemic therapy (chemotherapy, hormones, immunotherapy), made a blanket refusal of all recommended treatment, or refused all treatment before any was recommended.
If a patient opts for an alternative therapy that is not recommended, it is equivalent to a refusal of treatment.
The first course of therapy is no treatment when the patient refuses all treatment. Abstractors should code all treatment data items to Refused.
Abstractors should code all treatment data items to Refused.
CS Note: VERIFY TUMOR SIZE - 2 CM ON IMAGING. FACILITY RESPONSE: RULES FOR STAGING BOTH AJCC AND SEER STATE WE CANNOT USE MRI /IMAGING FOR PROSTATE STAGING - SO CAN WE USE IT FOR TMR SIZE? WE HAD ANOTHER CASE IN THE PAST WITH SAME ISSUE IN QC - TRADITIONALLY I TELL MY TEAM FOR PROSTATE THEY CAN’T USE INFO FROM MRI IS THERE ELSEWHERE IN THE MANUALS THAT ALLOWS US TO APPLY OTHER IMAGING TUMOR SIZE RULES TO PROSTATE CASES?
Answer: Please do not apply rules for one data item to another one. This can cause miscoding and confusion. Please review the Tumor Size rules to determine how to code Tumor Size Summary. EOD and AJCC rules do not apply. Also, because tumor size for prostate is irrelevant and very hard to determine accurately, we recommend coding Tumor Size 999.
03/04/2026 BIOPSY IS AN FNA AND ISN’T THERE A RULE THAT YOU CANNOT CODE THAT AS DIAGNOSIS DATE OFF OF AMBIGUOUS TERMINOLOGY (SUSPICIOUS FOR). ADDED FNA INTO THE BIOPSY TEXT.
Answer: If cytology has an ambiguous term, you can use it as the date of diagnosis. Ambiguous cytology is not diagnostic of cancer. Any suspicious cytology must be confirmed by biopsy, resection, or a statement by the physician that the patient has cancer. FNA is a diagnostic confirmation 1.
CAN YOU ASSIGN HISTOLOGY CODE 8071 KERATINIZING SCC FOR ESOPHAGUS (C15.4), WHICH IS NOT LISTED AS A SUBTYPE IN STRS TABLE 5 FOR ESOPHAGUS HISTOLOGIES FOR SCC 8070. THE HISTOLOGY CODE 8071 IS A VALID CODE FOR ESOPHAGUS WHEN YOU CONDUCT A SEARCH ON THE CANCER PATH CHART PLATFORM.
Answer: Not all histologies are listed in the STR, Squamous cell carcinoma, keratinizing, NOS (8071/3) is a valid code for the esophagus.
Facility response: THAT WAS OBTAINED FROM THE PATH REPORT AND IS INCLUDED IN PATH TEXT. IT WAS NOT IN THE OP TEXT AND THAT IS WHY IT IS NOT INCLUDED THERE. WE ARE TOLD NOT TO REPEAT INFO FOUND IN OTHER TEXT BOXES. I WILL NOT BE ADDED TO OP TEXT AS THE DOCTOR DID NOT INDICATE ANYWHERE IN HIS OP REPORT THAT HE REMOVED LYMPH NODES. WE FOUND THAT THEY WERE REMOVED PER PATH REPORT AND THAT IS WHERE THE INFO WAS COLLECTED.
Answer: Text documentation is required to justify coded values in the abstract, which includes all treatment fields and to supplement information not transmitted with coded values. NAACCR Data Item #2610 — Surgery Text should include:
Dates and text describing each surgical procedure performed as part of the first course treatment
Treatment plan
Date surgery was performed
Type of procedure
Facility where surgery was performed
Include lymph nodes removed and indicate if a sentinel node was removed
The surgery text will differ from the operative report findings.
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