IV_2 Diagnostic Confirmation

IV.2 Diagnostic Confirmation

Records the best method used to confirm the presence of the cancer being reported. The best method could occur at any time throughout the entire course of the disease. It is not limited to the confirmation at the time of initial diagnosis.

Coding Instructions:

Coding for the confirmation field is in the order of the conclusiveness of the method with the lowest number taking precedence over other codes. The most conclusive method, microscopic analysis of tissue, is therefore coded as 1, while microscopic analysis of cells, the next most conclusive method, is coded as 2.

Medical records must be studied to determine what methods were used to confirm the diagnosis of cancer. The most conclusive method should be coded in the confirmation field. As the confirmation field covers the patient's entire medical history, this code can be changed ANY TIME during the patient’s course of disease to a lower code.

Codes:

Code

Description

Microscopic Confirmation

POSITIVE HISTOLOGY

Use for microscopic confirmation based on biopsy, including punch biopsy, needle biopsy, bone marrow aspiration, curettage, and conization.

Code 1 includes:

Microscopic examination of frozen section specimens and surgically removed tumor tissue, whether taken from the primary or a metastatic site.
Leukemia only: Records a positive blood count (CBC or peripheral blood).
Cancers first diagnosed as a result of an autopsy or previously suspected and confirmed in an autopsy if microscopic examination is performed on the autopsy specimens.

POSITIVE CYTOLOGY, NO POSITIVE HISTOLOGY

Cytologic diagnoses based on microscopic examination of cells, rather than tissue.

Do not use code 2 if cancer is ruled out by a histologic examination.
Included is sputum, cervical, and vaginal smears; fine needle aspiration from breast or other organs; bronchial brushings and washings; tracheal washings; prostatic secretions; gastric, spinal, or peritoneal fluid; and urinary sediment, or urine cytology.

Also include diagnoses based on paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid.

CODE 3 is ONLY used for Hematopoietic and Lymphoid Neoplasms (9590/3-9992/3)

POSITIVE HISTOLOGY PLUS

Positive immunophenotyping AND/OR positive genetic studies

Code 3 is used when the following conditions are met:

Genetic testing and/or immunophenotyping are described in the Hematopoietic Database "Definitive Diagnostic Method", AND
Genetic testing and/or immunophenotyping were done, AND
Genetic testing and/or immunophenotyping were positive (proved the type of neoplasm being coded).

Flow cytometry is a test for immunophenotyping and also for genetic testing. It is coded for hematopoietic and lymphoid neoplasms using the directions above.

POSITIVE MICROSCOPIC CONFIRMATION, METHOD NOT SPECIFIED

Cases with a history of microscopic confirmation, but no information about whether based on examination of tissue or cells.

No Microscopic Confirmation

POSITIVE LABORATORY TEST OR MARKER STUDY

Clinical diagnosis of cancer based on certain laboratory tests or marker studies that are clinically diagnostic for cancer.

Examples are the presence of alpha fetoprotein (AFP) for liver cancer and an abnormal electrophoretic spike for multiple myeloma or Waldenstrom's macroglobulinemia.

Although an elevated PSA is nondiagnostic of cancer, if the physician uses the PSA as a basis for diagnosing prostate cancer with no other workup, record as code 5.

DIRECT VISUALIZATION WITHOUT MICROSCOPIC CONFIRMATION

Includes diagnoses by visualization and/or palpation during surgical or endoscopic exploration, or by gross autopsy.

Do not use code 6 if visualization or palpation during surgery or endoscopy is confirmed by a positive histology or cytology report.

RADIOGRAPHY WITHOUT MICROSCOPIC CONFIRMATION

Includes all diagnostic radiology, scans, ultrasound, and other imaging technologies not confirmed by a positive histologic or cytologic report or by direct visualization.

CLINICAL DIAGNOSIS ONLY (Other than 5, 6, or 7)

Cases diagnosed by clinical methods other than direct visualization and/or palpation during surgery, endoscopy, or gross autopsy, if not confirmed microscopically.

UNKNOWN WHETHER OR NOT MICROSCOPICALLY CONFIRMED

(Death Certificate Only cases are included in code 9.)