VI_2_4 Surgery of Other Regional Sites, Distant Sites, or Distant Lymph Nodes

VI.2.4 Surgery of Other Regional Sites, Distant Sites, or Distant Lymph Nodes

This field refers to the surgical removal of sites other than the primary site. There are three one-character fields to be used to record removal of tissue other than the primary tumor or organ of origin. This would not include an en bloc resection.

Coding Instructions:

RX Summ - Surg Oth Reg/Dis and its corresponding procedure fields are not coded according to site. Rather, they are coded using a single scheme for all sites. This applies to cases diagnosed January 1, 2003 and forward.

Code the removal of non-primary site tissue which the surgeon may have suspected to be involved with malignancy even if the pathology was negative.

Example:

The patient has an excisional biopsy of a hard palate lesion removed from the roof of the mouth and a resection of a metastatic lung nodule during the same procedure.

Code the resection of the lung nodule as 4 (distant site).

Do not code the incidental removal of tissue for reasons other than malignancy.

Example:

During a colon resection, the surgeon noted that the patient had cholelithiasis and removed the gallbladder.

Do not code removal of the gallbladder.

Procedures are to be entered in chronological order.

If no surgery was performed of other regional or distant sites or distant lymph nodes, leave the fields blank.

Note: Use code 1 if any surgery is performed to treat tumors of Unknown or Ill-defined Primary sites (C76.0-76.8, C80.9) or for Hematopoietic/Reticuloendothelial/Immunoproliferative disease (C42.0, C42.1, C42.3, C42.4, or M-9727, 9733, 9741-9742, 9764-9809, 9832, 9840-9931, 9945-9946, 9950-9967, and 9975-9992.)

Use code 1 when the involved contralateral breast is removed for a single breast cancer.

Codes:

Code

Description

NONE

No surgical procedure of nonprimary site

NONPRIMARY SURGICAL PROCEDURE PERFORMED

Nonprimary surgical resection to other site(s), unknown if whether the site(s) is regional or distant.

NONPRIMARY SURGICAL PROCEDURE TO OTHER REGIONAL SITES

Resection of regional site.

NONPRIMARY SURGICAL PROCEDURE TO DISTANT LYMPH NODE(S)

Resection of distant lymph node(s).

NONPRIMARY SURGICAL PROCEDURE TO DISTANT SITE

Resection of distant site.

COMBINATION OF CODES

Any combination of surgical procedures 2, 3, or 4.

UNKNOWN

It is unknown whether any surgical procedure of a nonprimary site was performed. Death certificate only.

Code	Description
0	NONE No surgical procedure of nonprimary site
1	NONPRIMARY SURGICAL PROCEDURE PERFORMED Nonprimary surgical resection to other site(s), unknown if whether the site(s) is regional or distant.
2	NONPRIMARY SURGICAL PROCEDURE TO OTHER REGIONAL SITES Resection of regional site.
3	NONPRIMARY SURGICAL PROCEDURE TO DISTANT LYMPH NODE(S) Resection of distant lymph node(s).
4	NONPRIMARY SURGICAL PROCEDURE TO DISTANT SITE Resection of distant site.
5	COMBINATION OF CODES Any combination of surgical procedures 2, 3, or 4.
9	UNKNOWN It is unknown whether any surgical procedure of a nonprimary site was performed. Death certificate only.