California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures for Hospitals
(Except for M-9727, 9733, 9741-9742, 9764-9809, 9832, 9840-9931, 9945-9946, 9950-9967, 9975-9992)
Code |
Description |
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00 |
None; no surgery of primary site; autopsy only |
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19 |
Local tumor destruction, NOS Note: No specimen was sent to pathology for surgical events coded 19 (principally for cases diagnosed prior to January 1, 2003). |
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Procedures coded 20-24 remove the gross primary tumor and some of the breast tissue (breast-conserving or preserving). There may be microscopic residual tumor. Specimen sent to pathology for surgical events coded 20-80. |
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20 |
Partial mastectomy, NOS; less than total mastectomy, NOS [formerly SEER code 10] |
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21 |
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Partial mastectomy WITH nipple resection [formerly SEER code 11 = nipple resection] |
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22 |
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Lumpectomy or excisional biopsy [formerly SEER code 12] |
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23 |
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Reexcision of the biopsy site for gross or microscopic residual disease [formerly SEER code 13] |
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24 |
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Segmental mastectomy (including wedge resection, quadrantectomy, tylectomy) [formerly SEER codes 16 = segmental mastectomy, 14 = wedge resection, 15 = quadrantectomy, 17 = tylectomy] |
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30 |
Subcutaneous mastectomy Note: A subcutaneous mastectomy, also called a nipple sparing mastectomy, is the removal of breast tissue without the nipple and areolar complex or overlying skin. It is performed to facilitate immediate breast reconstruction. Cases coded 30 may be considered to have undergone breast reconstruction. |
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40 |
Total (simple) mastectomy, NOS |
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41 |
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WITHOUT removal of uninvolved contralateral breast |
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43 |
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WITH reconstruction NOS |
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44 |
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Tissue |
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45 |
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Implant |
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46 |
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Combined (Tissue and Implant) |
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42 |
WITH removal of uninvolved contralateral breast |
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47 |
WITH reconstruction NOS |
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48 |
Tissue |
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49 |
Implant |
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75 |
Combined (Tissue and Implant) |
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Notes: A total (simple) mastectomy removes all breast tissue, the nipple, and areolar complex. An axillary dissection is not done, but sentinel lymph nodes may be removed. For single primaries only, code removal of involved contralateral breast under the data item Surgical Procedure/Other Site or Surgical Procedure/Other Site at This Facility. If contralateral breast reveals a second primary, each breast is abstracted separately. The surgical procedure is coded 41 for the first primary. The surgical code for the contralateral breast is coded to the procedure performed on that site. Reconstruction that is planned as part of first course treatment is coded 43-49 or 75, whether it is done at the time of mastectomy or later. |
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76 |
Bilateral mastectomy for a single tumor involving both breasts, as for bilateral inflammatory carcinoma. | ||||
50 |
Modified radical mastectomy | ||||
51 |
Without removal of uninvolved contralateral breast | ||||
53 |
Reconstruction, NOS | ||||
54 |
Tissue |
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55 |
Implant |
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56 |
Combined (Tissue and Implant) |
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52 |
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With removal of uninvolved contralateral breast |
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57 |
Reconstruction, NOS | ||||
58 |
Tissue |
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59 |
Implant |
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63 |
Combined (Tissue and Implant) |
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Notes: Removal of all breast tissue, the nipple, the areolar complex, and variable amounts of breast skin in continuity with the axilla. The specimen may or may not include a portion of the pectoralis major muscle. [SEER Guideline: in continuity with or "en bloc" means that all of the tissues were removed during the same procedure, but not necessarily in a single specimen] [SEER Guideline: "tissue" for reconstruction is defined as human tissue such as muscle (latissimus dorsi or rectus abdominis) or skin in contrast to artificial prostheses (implants).] If contralateral breast reveals a second primary, it is abstracted separately. The surgical procedure is coded 51 for the first primary. The surgical code for the contralateral breast is coded to the procedure performed on that site. For single primaries only, code removal of involved contralateral breast under the data item Surgical Procedure/Other Site or Surgical Procedure/Other Site at This Facility. |
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60 |
Radical mastectomy, NOS |
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61 |
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Without removal of uninvolved contralateral breast |
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64 |
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Reconstruction, NOS |
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65 |
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Tissue |
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66 |
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Implant |
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67 |
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Combined (Tissue and Implant) |
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62 |
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With removal of uninvolved contralateral breast [SEER Guideline: Removal of breast tissue, nipple, areolar complex, variable amount of skin, pectoralis minor, pectoralis major. Includes en bloc axillary dissection. For single primaries only, code removal of involved contralateral breast under the data item "Surgery of other regional sites, distant sites, or distant lymph nodes."] |
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68 |
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Reconstruction, NOS |
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69 |
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Tissue |
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73 |
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Implant |
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74 |
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Combined (Tissue and Implant) |
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70 |
Extended radical mastectomy [SEER Guideline: Removal of breast tissue, nipple, areolar complex, variable amount of skin, pectoralis minor, pectoralis major. Includes removal of internal mammary nodes and en bloc axillary dissection. For single primaries only, code removal of involved contralateral breast under the data item "Surgery of other regional sites, distant sites, or distant lymph nodes."] |
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71 |
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Without removal of uninvolved contralateral breast |
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72 |
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With removal of uninvolved contralateral breast |
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80 |
Mastectomy, NOS |
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90 |
Surgery, NOS |
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99 |
Unknown if cancer-directed surgery performed; death certificate only |
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