V.4.2.2 Mets at Diagnosis – Brain

Coding Instructions:

• Code information about brain metastasis only (discontinuous or distant) to the brain identified at the time of diagnosis.

NOTE: Spinal cord involvement is NOT coded in this field. See Mets at Diagnosis – Other.

• Metastatic involvement may be single (one focus of metastatic disease) or multiple (multiple foci of metastatic disease in the same site or multiple sites).

• Information regarding brain involvement may be clinical or pathologic.

• Code this field for brain metastasis even if the patient had neoadjuvant (preoperative) systemic therapy, unless it is determined to be disease progression.

• Code brain involvement in this field for all solid tumors, Kaposi’s sarcoma, Lymphomas, Unknown primary site and Other and Ill-defined primary sites.  

• Code this field for Lymphomas of all sites for the histologies (9590-9699, 9702-9727, 9735, 9737-9738, 9811-9818, 9823, 8927, and 9737).

• Assign the code that best describes whether the case has brain metastasis at diagnosis.

• Use code 0 when the medical record:

• Indicates no distant (discontinuous) metastases to the brain. Including:

• A negative clinical or pathologic statement

• Negative imaging reports

• Mentions (discontinuous) metastasis but brain is not stated as the involved site.

• Use code 1 when the medical record confirms:

• The patient has distant (discontinuous) metastasis and the brain is mentioned as involved.

• The patient is diagnosed with an unknown primary (C80.9) and brain is mentioned as a distant metastatic site.

• Use code 8 (Not applicable) for the following site/histology combinations for which a code for distant metastasis is not clinically relevant:

• Use code 9 when the patient is known to have distant metastasis but it cannot be determined whether the distant metastasis include brain.

Codes:

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