V.2 Laterality

Coding Instructions:

• Laterality must be coded for all paired sites (see Section V.2.1 Paired Sites)

• Laterality may be coded for sites other than those required: for example, thyroid.

• DO NOT code metastatic sites as bilateral involvement.

• Code 0 is appropriate for non-paired sites, not otherwise specified.

• Primary Site is unknown (C809)

• Assign code 3 if the laterality is not known but the tumor is confined to a single side of the paired organ.

Example:

Pathology report: Patient has a 2 cm carcinoma in the upper pole of the kidney. Code laterality as 3 because there is documentation that the disease exists in only one kidney, but it is unknown if the disease originated in the right or left kidney.

• Code 4 is seldom used EXCEPT for the following:

• Both ovaries involved simultaneously, single histology

• Diffuse bilateral lung nodules

• Bilateral retinoblastomas

• Bilateral Wilms Tumors

• Never use code 4 for bilateral primaries for which separate abstracts are prepared or when the side of origin is known and the tumor has spread to the other side.

Example:

A left ovarian primary with metastases to the right ovary is code 2, rather than code 4.

• Assign code 5 when the tumor originates in the midline of a paired organ or site (effective with 1/1/2010 dx).

Example:
Patient has an excision of a melanoma located above the umbilicus

Note: “Midline of the right breast” is coded 1. Midline in this scenario indicates the primary site is C50.8 (overlapping sites).

• Malignant and Benign/Borderline Brain and CNS tumors specific:

• Site code C70.0, C71.0-C71.4, C72.2 diagnosed January 1, 2004 and forward require a laterality codes 1-5 or 9

• All other CNS/brain subsites of C70, C71, and C72 are coded: Laterality 0 (not a paired organ) regardless of the date of diagnosis. All pituitary and pineal gland and craniopharyngeal duct tumors (C75.1-3) are coded Laterality = 0 (not a paired site).

• All primary brain and CNS tumors diagnosed prior to January 1, 2004, are coded: Laterality 0 (not a paired site).

• Assign code 9 when the neoplasm originated in a paired site and the laterality is unknown AND there is no statement that only one side of the paired organ is involved.

Codes:

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