05-01-2026 Gleason Tertiary Pattern
Scenario: Snip from Radical Prostatectomy
Question: How would you code the SSDI Gleason Tertiary Pattern?
- 40, Tertiary pattern 4
- X9, Not documented in medical record/ Gleason Tertiary Pattern not assessed or unknown if assessed
Answer: X9, Not documented in medical record/ Gleason Tertiary Pattern not assessed or unknown if assessed
SSDI Manual Gleason Tertiary Pattern
- Record the tertiary pattern documented on radical prostatectomy or autopsy only. Record the tertiary pattern prior to neoadjuvant treatment.
Discussion: At this time, the appropriate term to record is Tertiary Pattern. We have not yet received formal guidance indicating that an alternative term may be used. Since the term Tertiary Pattern is not mentioned in the path report, record as X9 not documented.
CAnswer forum post https://cancerbulletin.facs.org/forums/node/161933
