Scenario:
Path Cap Summary Margins: Negative
In the gross description I find this information
Distance of mass to:
Proximal margin: 14 cm
Distal margin: 11 cm
Mesenteric vascular margin: 3.6 cm
Question: How will you assign the SSDI Circumferential Resection Margin?
- 6
- 0
- 1 Margins clear, distance from tumor not stated
- 9 Not documented in medical record
Answer: 36.0
Discussion & Rational: The Mesenteric Vascular Margin is stated to be 3.6 cm, which is considered the same thing as “mesenteric margin”, so you will be able to use this value to code the SSDI CRM. This field is documented in millimeters, thus 3.6cm is equivalent to 36 mm, so document the SSDI as 36.0.
SSDI Manual Circumferential Resection Margin (CRM)
Note 5: The CRM may be referred to as
- Circumferential radial margin
- Circumferential resection margin
- Mesenteric (mesocolon) (mesorectal) margin
- Radial margin
- Soft tissue margin
