VI_7 Transplant/Endocrine Procedures and Codes

VI.7 Transplant/Endocrine Procedures and Codes

Record systemic therapeutic procedures administered as part of first course of treatment. For reporting purposes, endocrine surgery is defined as the total surgical removal of an endocrine gland (both glands or all of a remaining gland in the case of paired glands).

Coding Instructions:

Procedures included for transplant/endocrine are:

Bone marrow transplants
Stem cell harvests
Surgical and/or radiation endocrine therapy

Use Code 20 for umbilical code stem cell transplant (single or double)

Use Code 88 when the patient does not have a rescue.

Referral to a specialist for hematologic transplant or endocrine procedures is considered a recommendation. Follow-up on these cases is required to determine whether a procedure was performed or not, and code accordingly. This applies to cases diagnosed January 1, 2010 and forward.

Information on transplants and endocrine procedures was removed from the Rx Summ-BRM (Immunotherapy) field and moved to this field. Bone marrow and stem cell procedures are now coded in this field along with endocrine surgery or radiation.

Record endocrine surgery for treatment of cancer of the breast or prostate only. The procedures are:

Adrenalectomy
Hypophysectomy
Oophorectomy (breast)
Orchiectomy (prostate)

If tumor tissue is present in a gland removed in the course of endocrine therapy, record the procedure as surgical treatment also.

Report any type of radiation directed toward an endocrine gland to affect hormonal balance if:

The treatment is for cancers of the breast and prostate.
Both paired glands (ovaries, testes, adrenals) or all of a remaining gland have been irradiated.

Notes:

For recording therapy at this facility, do not use code 99 if Class of Case is coded to 00, 30 or 31.

Use the following codes for recording transplant/endocrine procedures in the Summary field.

Use codes 00-87 for recording transplant/endocrine procedures in the "at this facility field."

Codes:

Code

Description

No transplant procedure or endocrine therapy was administered as part of the first course therapy.

A bone marrow transplant procedure was administered, but the type was not specified.

Bone marrow transplant - autologous.

Bone marrow transplant - allogeneic.

Syngeneic bone marrow transplant (identical twin).

Stem cell harvest.

Endocrine surgery and/or endocrine radiation therapy

Combination of endocrine surgery and/or radiation with a transplant procedure. (combination of codes 30 and 10, 11, 12, or 20).

Hematologic transplant and/or endocrine surgery/radiation were not recommended/administered because it was contraindicated due to patient risk factors (i.e., comorbid conditions, advanced age).

Hematologic transplant and/or endocrine surgery/radiation were not administered because the patient died prior to planned or recommended therapy.

Hematologic transplant and/or endocrine surgery/radiation were not administered. It was recommended by the patient's physician, but was not administered as part of the first course therapy. No reason was stated in patient record.

Hematologic transplant and/or endocrine surgery/radiation were not administered. It was recommended by the patient's physician, but this treatment was refused by the patient, a patient's family member, or the patient's guardian. The refusal was noted in patient record.

Hematologic transplant and/or endocrine surgery/radiation was recommended, but it is unknown if it was administered.

It is unknown whether hematologic transplant and/or endocrine surgery/radiation was recommended or administered because it is not stated in patient record. Death certificate only.