Q.1: CORPUS UTERI

For Cases Diagnosed prior to January 1, 2003

Corpus uteri C54.0-C54.9, Uterus NOS C55.9
SURGICAL APPROACH

 

Code

Description

0

None; no cancer-directed surgery of primary site

1

Vaginal, NOS

2

 

Not assisted by endoscopy

3

 

Assisted by colposcopy

4

 

Assisted by laparoscopy

5

Open, NOS

6

 

Not assisted by endoscopy

7

 

Assisted by endoscopy

9

Unknown; not stated; death certificate only

 

SURGERY OF PRIMARY SITE

For invasive cancers, dilation and curettage is coded as an incisional biopsy (02) under the data item Non-Cancer-Directed Surgery.

 

Code

Description

00

None; no cancer-directed surgery of primary site

10

Local tumor destruction, NOS

Note: without pathology specimen.

11

 

Photodynamic therapy (PDT)

12

 

Electrocautery; fulguration

Note: Includes use of hot forceps for tumor destruction.

13

 

Cryosurgery

14

 

Laser

15

 

LEEP

Note: No specimen sent to pathology from this surgical event.

20

Local tumor destruction or excision, NOS; simple excision, NOS

Note: with pathology specimen.

Note: Procedures in code 20 include but are not limited to:

  • Cryosurgery

  • Electrocautery

  • Excisional biopsy

  • Laser ablation

  • Thermal ablation.

21

 

Electrocautery

22

 

Cryosurgery

23

 

Laser

24

 

Excisional biopsy

25

 

Polypectomy

26

 

Myomectomy

Note: Specimen sent to pathology from this surgical event. Margins of resection may have microscopic involvement.

30

Subtotal hysterectomy/supracervical hysterectomy/fundectomy with or without removal of tube(s) and ovary(ies).

31

 

Without tube(s) and ovary(-ies)

32

 

With tube(s) and ovary(-ies)

Note: Cervix left in place.

40

Total hysterectomy (simple, pan ) without removal of tube(s) and ovary(-ies)

Note: Removes both the corpus and cervix uteri. It may also include a portion of the vaginal cuff.

50

Total hysterectomy (simple, pan ) with removal of tube(s) or ovary(-ies)

Note: Removes both the corpus and cervix uteri. It may also include a portion of the vaginal cuff.

60

Modified radical or extended hysterectomy; radical hysterectomy; extended radical hysterectomy

61

 

Modified radical hysterectomy

62

 

Extended hysterectomy

63

 

Radical hysterectomy; Wertheim's procedure

64

 

Extended radical hysterectomy

70

Hysterectomy, NOS, with or without removal of tube(s) and ovary(-ies)

71

 

Without removal of tube(s) and ovary(-ies)=

72

 

With removal of tube(s) and ovary(-ies)

80

Pelvic exenteration

81

 

Anterior exenteration

Note: Includes bladder, distal ureters, and genital organs with their ligamentous attachments and pelvic lymph nodes. The removal of pelvic lymph nodes is also coded under the data item Surgery of Other Regional Site(s), Distant Site(s), or Distant Lymph Node(s).

82

 

Posterior exenteration

Note: Includes rectum and rectosigmoid with ligamentous attachments and pelvic lymph nodes. The removal of pelvic lymph nodes is also coded under the data item Surgery of Other Regional Site(s), Distant Site(s), or Distant Lymph Node(s).

83

 

Total exenteration

Note: Includes removal of all pelvic contents and pelvic lymph nodes. The removal of pelvic lymph nodes is also coded under the data item Surgery of Other Regional Site(s), Distant Site(s), or Distant Lymph Node(s).

84

 

Extended exenteration

Note: Includes pelvic blood vessels or bony pelvis.

90

Surgery, NOS

99

Unknown if cancer-directed surgery performed; death certificate only

 

SURGICAL MARGINS

 

Code

Description

0

All margins grossly and microscopically negative

1

Margins involved, NOS

2

 

Microscopic involvement

5

 

Macroscopic involvement

7

Margins not documented

8

No cancer-directed surgery of primary site

9

Unknown whether margins were involved or negative; death certificate only

 

SCOPE OF REGIONAL LYMPH NODE SURGERY

The regional lymph nodes are:

 

Code

Description

0

No regional lymph nodes removed

1

Regional lymph nodes removed, NOS

2

  

Pariaortic with or without other regional lymph nodes

9

Unknown; not stated; death certificate only

 

NUMBER OF REGIONAL LYMPH NODES EXAMINED

 

Code

Description

00

No regional lymph nodes removed

01

One regional lymph node removed

02

Two regional lymph nodes removed

..

 

90

Ninety or more regional lymph nodes removed

95

No regional lymph nodes removed but aspiration of regional lymph nodes was performed

96

Regional lymph node removal documented as a sampling and number of lymph nodes unknown/not stated

97

Regional lymph node removal documented as dissection and number of lymph nodes unknown/not stated

98

Regional lymph nodes surgically removed but number of lymph nodes unknown/not stated and not documented as sampling or dissection

99

Unknown; not stated; death certificate only

 

SURGERY OF OTHER REGIONAL SITE(S), DISTANT SITE(S) OR DISTANT LYMPH NODE(S)

Do not code the incidental removal of an appendix. Do not code an omentectomy if it was the only surgery performed in addition to hysterectomy. Incidental removal is when an organ is removed for a reason unrelated to the malignancy.

 

Code

Description

0

None; no surgery to other regional or distant sites

1

Surgery to other sites or nodes, NOS; unknown if regional or distant

2

 

Other regional sites

3

 

Distant lymph nodes, NOS

4

 

 

Periaortic lymph nodes

5

  

Distant sites

6

  

Combinations of 5 with 4

7

 

Combination of 5 with 2 or 3

9

Unknown; not stated; death certificate only

 

RECONSTRUCTION/RESTORATION - FIRST COURSE

 

Code

Description

0

No reconstruction/restoration

1

Vaginal reconstruction

2

Urinary reconstruction

3

Bowel reconstruction/restoration

4

Combination of 3 with 1 or 2

8

Reconstruction/restoration recommended, unknown if performed

9

Unknown; not stated; death certificate only

 

 

<< Prev.       Next >>