Q.1: KIDNEY, RENAL PELVIS & URETER

For Cases Diagnosed prior to January 1, 2003

Kidney C64.9, Renal Pelvis C65.9, Ureter C66.9
SURGICAL APPROACH

 

Code

Description

0

None; no cancer-directed surgery of primary site

1

Endoscopy, NOS

2

 

Not image guided

3

 

Image guided

4

Open, NOS

5

 

Not assisted by endoscopy

6

 

Assisted by endoscopy

9

Unknown; not stated; death certificate only

 

SURGERY OF PRIMARY SITE

 

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

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

20

Local tumor destruction or excision, NOS

Note: with pathology specimen.

21

 

Photodynamic therapy (PDT)

22

 

Electrocautery

23

 

Cryosurgery

24

 

Laser ablation

25

 

Laser excision

26

 

Polypectomy

27

 

Excisional biopsy

Note: Specimen sent to pathology from this surgical event.

30

Partial or subtotal nephrectomy (kidney or renal pelvis) or partial ureterectomy (ureter)

Note: Margins of resection are grossly negative. There may be microscopic involvement.

Note: Procedures coded 30 include, but are not limited to:

  • Cryosurgery

  • Electrocautery

  • Excisional biopsy

  • Laser

  • Segmental resection

  • Thermal ablation

  • Wedge resection

40

Complete/total/simple nephrectomy for kidney parenchyma

Nephroureterectomy

Note: Includes bladder cuff for renal pelvis or ureter.

50

Radical nephrectomy

Note: May include removal of a portion of vena cava, adrenal gland(s), Gerota's fascia, perinephric fat, or partial/total ureter.

70

Any nephrectomy (simple, subtotal, complete, partial, simple, total, radical) plus an en bloc resection of other organ(s) (colon, bladder)

Note: The other organs, such as colon or bladder, may be partially or totally removed.

80

Nephrectomy, NOS

Ureterectomy, NOS

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

 

Site

Subsite

Kidney
  • Aortic (para-aortic, periaortic, lateral aortic)
  • Paracaval
  • Renal hilar
  • Retroperitoneal, NOS

Renal pelvis
  • Aortic
  • Paracaval
  • Renal hilar
  • Retroperitoneal, NOS

Ureter
  • Iliac (common, internal [hypogastric], external)
  • Paracaval
  • Pelvic, NOS
  • Periureteral
  • Renal hilar

 

Code

Description

0

No regional lymph nodes removed

1

Regional lymph nodes removed, NOS; not stated if bilateral or unilateral

2

 

Unilateral regional lymph nodes

3

 

Bilateral 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 ribs during the operative approach.

 

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

4

 

Distant sites

5

  

Combination of 4 with 2 or 3

9

Unknown; not stated; death certificate only

 

RECONSTRUCTION/RESTORATION - FIRST COURSE

 

Code

Description

0

No reconstruction/restoration

1

Kidney transplant (primary site)

8

Reconstruction/restoration recommended, unknown if performed

9

Unknown; not stated; death certificate only

 

 

<< Prev.       Next >>