Q.1: RECTUM

For Cases Diagnosed prior to January 1, 2003

C20.9
SURGICAL APPROACH

 

Code

Description

0

None; no cancer-directed surgery of primary site

1

Endoscopy, NOS (includes laparoscopic)

4

Open, NOS

5

 

Transanal (Kraske, York Mason)

6

 

Posterior; coccygeal; trans-sacral; abdominosacral

7

 

Low anterior (LAR)

8

 

Abdominal perineal (AP)

9

Unknown; not stated; death certificate only

 

SURGERY OF PRIMARY SITE

CODE removal/surgical ablation of single or multiple liver metastases under the data item Surgery of Other Regional Site(s), Distant Site(s) or Distant Lymph Node(s).

 

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

28

 

Curette and fulguration

Note: Specimen sent to pathology from this surgical event.

30

Wedge or segmental resection; partial proctectomy, NOS

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

  • Anterior resection

  • Hartmann's operation

  • Low anterior resection (LAR)

  • Trans sacral rectosigmoidectomy

40

Pull through with sphincter preservation (colo-anal anastomosis)

Note: Procedures coded 40 include but are not limited to:

  • Altemeier's operation

  • Duhamel's operation

  • Soave's submucosal resection

  • Swenson's operation

  • Turnbull's operation

50

Total proctectomy

Note: Procedures coded 50 include but are not limited to:

  • Abdominoperineal resection (A & P resection)

  • Anterior/posterior (A/P) resection/Miles' operation

  • Rankin's operation

60

Total proctocolectomy, NOS

70

Proctectomy or proctocolectomy with an en bloc resection of other organs; pelvic exenteration

Note: En bloc resection is the removal of organs in one piece at one time. The creation of an ileal reservoir, which is a part of a pelvic exenteration, should be coded in the data item Reconstruction/Restoration.

80

Proctectomy, 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

The pathology report often identifies regional lymph nodes by their anatomic location: mesenteric nodes; perirectal nodes; rectal nodes.

The specific regional lymph nodes are:

Superior mesenteric, external iliac and common iliac nodes are classified as distant lymph nodes.  Code removal of these nodes under the data item Surgery of Other Regional Site(s), Distant Site(s), or Distant Lymph Node(s).

 

Code

Description

0

No regional lymph nodes removed

1

Regional lymph nodes removed, NOS

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 appendix, gallbladder, bile ducts, or spleen. Incidental removal is when an organ is removed for a reason unrelated to the malignancy (gallbladder removed for obvious cholelithiasis).

 

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

  

Removal of other regional sites, only

3

  

Removal/surgical ablation of single liver metastasis

4

  

Removal/surgical ablation of multiple liver metastases

5

  

Combination of codes 2 with 3 or 2 with 4

6

 

Removal of other distant sites or distant lymph nodes, only

7

 

Combination of code 6 with 3, 4 or 5

8

 

Combination of code 6 with 3 or 5

9

Unknown; death certificate only

 

RECONSTRUCTION/RESTORATION - FIRST COURSE

 

Code

Description

0

No reconstruction/restoration

1

Colostomy (permanent)

2

Ileostomy, NOS

3

  

Without a reservoir or pouch

4

  

With an abdominal reservoir or pouch

5

  

With an anal reservoir or pouch; artificial sphincter

9

Unknown; not stated; death certificate only

 

 

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