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Coding Guidelines for Head and Neck Tumors: Sites and Histology

This resource provides comprehensive coding guidelines specific to head and neck tumors, emphasizing the correct identification of primary sites for tumors. It outlines the procedures for coding based on biopsy results, staging assignments, and the importance of tumor resection reports. Included are definitions, charts, and tables to assist in accurately determining histology groups and tumors’ origins. With a focus on the AJCC staging system and various medical records, this work serves as an essential guide for healthcare professionals involved in oncology coding.

samuel-hodge
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Coding Guidelines for Head and Neck Tumors: Sites and Histology

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  1. Head and Neck

  2. Equivalent Terms, Definitions, Charts, Tables and Illustrations • Primary site • Do not code biopsy site

  3. Priority Order Code Primary Site • Tumor Board a. Specialty b. General

  4. Priority Order Code Primary Site • Staging physician’s site assignment a. AJCC staging form b. TNM statement in medical record If neither 1 or 2 available, based on whether tumor was resected

  5. Priority Order Code Primary Site • Total resection of primary tumor (margins may be microscopically positive) a. Operative report – surgeon’s statement b. Final diagnosis on pathology report

  6. Priority Order Code Primary Site • No resection (may have biopsy) a. Endoscopy b. Radiation oncologist c. Diagnosing physician d. Primary care physician Continued on next slide

  7. Priority Order Code Primary Site e. Other physician f. Diagnostic imaging g. Physician statement based on clinical examination

  8. Default Site Codes • Point of origin cannot be determined • C02.8 Overlapping lesion of tongue • C08.8 Overlapping lesion of major salivary glands • C14.8 Overlapping lesion of lip, oral cavity, and pharynx.

  9. Table 1 – Paired Sites

  10. Chart 1 – H&N Histology Groups and Specific Types Use this chart with the histology rules to code the most specific histologic term. The tree is arranged in descending order. Each branch is a histology group, starting with the NOS or group terms and descending into the specific types for that group. As you follow the branch down, the terms become more specific

  11. Multiple Primary Rules

  12. Unknown if Single or Multiple Tumors

  13. Single Tumor

  14. Multiple Tumors

  15. Histology Rules

  16. Single Tumor

  17. Multiple Tumors Abstracted as a Single Primary

  18. MP/H Task Force

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