Q.1: ORAL

For Cases Diagnosed prior to January 1, 2003

Lip C00.0-C00.9, Base of Tongue C01.9, Other Parts of Tongue C02.0-C09.9,
Gum C03.0-C03.9, Floor of Mouth C04.0-C04.9, Palate C05.0-C05.9
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)

Note: PDT: Exposing photo-sensitive drugs to specific wave lengths of light in the presence of oxygen causing drug to become cytotoxic.

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.

Procedures in codes 20-27 include, but are not limited to: Shave; Wedge resection

20

Local tumor 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

Wide excision, NOS

Note: Procedures in code 30 include, but are not limited to:

  • Hemiglossectomy

  • Partial glossectomy

Procedures in codes 40-43 include, but are not limited to: Radical glossectomy

40

Radical excision of tumor, NOS

41

 

Radical excision of tumor only

42

 

Combination of 41 with en bloc mandibulectomy (marginal, segmental, hemi , or total)

43

 

Combination of 41 with en bloc maxillectomy (partial, subtotal, total)

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

Regional cervical lymph nodes are:

 

Code

Description

0

None; no surgery to other regional or distant sites

1

Regional lymph nodes removed, NOS

2

 

Neck dissection, NOS

3

 

 

Selective, limited; nodal sampling; "berry picking"

4

 

 

Modified/modified radical

5

 

 

Radical

9

Unknown; not stated; death certificate only

 

Terminology of neck dissection (Robbins et al. 1991): A radical neck dissection includes the removal of all ipsilateral cervical lymph node groups, i.e., lymph nodes from levels I through V (submental, submandibular, cranial jugular, medial jugular, caudal jugular, dorsal cervical nodes along the accessory nerve, and supraclavicular), and removal of the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle. In a modified radical neck dissection the same lymph nodes are removed as in a radical neck dissection; however, one or more non lymphatic structures are preserved. A selective neck dissection preserves one or more lymph node groups routinely removed in radical neck dissection.

 

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)

 

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

 

 

Mandibulectomy (marginal, segmental, hemi , or total)

4

 

 

Maxillectomy (partial, subtotal, or total)

Note: Code a mandibulectomy or a maxillectomy in this field only if the procedure is not a part of an en bloc resection of the primary tumor. If the mandibulectomy or maxillectomy is a part of an en bloc resection of the primary tumor, code under Surgery of Primary Site.

5

 

Distant lymph nodes

6

 

Distant sites

7

 

Combination of 6 with 2, 3, 4, or 5

9

Unknown; not stated; death certificate only

 

RECONSTRUCTION/RESTORATION - FIRST COURSE

 

Code

Description

0

No reconstruction/restoration

1

Flaps, grafts, or any type of "plasty," NOS

2

  

Without implant/prosthesis

3

  

With implant/prosthesis

8

Reconstruction/restoration recommended, unknown if performed

9

Unknown; not stated; death certificate only

 

 

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