VI.2.4 Surgery of Other Regional Sites, Distant Sites, or Distant Lymph Nodes

Coding Instructions:

• RX Summ - Surg Oth Reg/Dis and its corresponding procedure fields are not coded according to site. Rather, they are coded using a single scheme for all sites.  This applies to cases diagnosed January 1, 2003 and forward.

• Code the removal of non-primary site tissue which the surgeon may have suspected to be involved with malignancy even if the pathology was negative.

Example:

The patient has an excisional biopsy of a hard palate lesion removed from the roof of the mouth and a resection of a metastatic lung nodule during the same procedure. Code the resection of the lung nodule as 4 (distant site).

• Do not code the incidental removal of tissue for reasons other than malignancy.

Example:

During a colon resection, the surgeon noted that the patient had cholelithiasis and removed the gallbladder. Do not code removal of the gallbladder.

• Procedures are to be entered in chronological order.

• If no surgery was performed of other regional or distant sites or distant lymph nodes, leave the fields blank.

• Codes 1-5 have priority over codes 0 and 9.

• Use code 1:

• If any surgery is performed to treat tumors of Unknown or Ill-defined Primary sites or for hematopoietic/reticuloendothelial/immunoproliferative disease.

• When the involved contralateral breast is removed for a single breast cancer.

• Use code 2 for sites that are regional.

• Use code 4 for sites that are distant.

• Do not code tissue or organs such as appendix that were removed incidentally, and the organ was not involved with cancer.

Note: Incidental removal of organs means that tissue was removed for reasons other than removing cancer or preventing the spread of cancer. The incidental removal of the appendix, gallbladder etc., during abdominal surgery, for example.

Codes:

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