Wiki Unknown if primary or metastatic

[BlakeCarswell82]

If the pathologist knows a salivary gland is malignant but is unable to determine if it is primary or metastatic, would it still be coded as unspecified?

"It is impossible to determine whether this arose primarily in the salivary gland or as metastatic from another site. Regardless, there is perineural invasion and the cauterized and inked margins are involved."

 

[PVAzCPC]

If the pathologist knows a salivary gland is malignant but is unable to determine if it is primary or metastatic, would it still be coded as unspecified?

"It is impossible to determine whether this arose primarily in the salivary gland or as metastatic from another site. Regardless, there is perineural invasion and the cauterized and inked margins are involved."

If I remember right, "uncertain behavior" denotes that the neoplasm cannot be determined if malignant or benign; "unspecified" denotes that
documentation does not specify whether it is malignant or benign. In my opinion then, this would be coded as 142.9 Malignant neoplasm of major salivary glands, (salivary gland unspecified), as pathology confirms malignant.

Coders are advised not to code by the NEOPLASM TABLE alone, so, to me, this makes the most sense

 

[LLynn29]

If I remember right, "uncertain behavior" denotes that the neoplasm cannot be determined if malignant or benign; "unspecified" denotes that
documentation does not specify whether it is malignant or benign. In my opinion then, this would be coded as 142.9 Malignant neoplasm of major salivary glands, (salivary gland unspecified), as pathology confirms malignant.

Coders are advised not to code by the NEOPLASM TABLE alone, so, to me, this makes the most sense

That is a very good reminder. Thanks!

 

[BlakeCarswell82]

Will it make a difference if it is coded as a primary site and then it eventually comes back that this was metastatic cancer?