10-24-2025
Scenario: 2025
- Laparoscopic Radical Left Nephrectomy:
- Poorly differentiated renal cell carcinoma with clear cell features, grade 4.
- Largest measurable dimension of carcinoma 4.5 cm.
- Carcinoma invades renal sinus fat and perinephric fat
- Soft tissue adipose tissue margin involved with carcinoma.
- Lymphovascular space invasion is present.
- Necrosis is present.
- Adrenal gland no neoplasia identified.
Question: How would you code the SSDI Invasion Beyond Capsule
- 0, Invasion beyond capsule not identified
- 1, Perinephric (beyond renal capsule) fat or tissue
- 2, Renal sinus
- 3, Gerota’s fascia
- 4, Any combination of codes 1-3
- 5, Invasion beyond capsule, NOS
Answer: 4, Any combination of codes 1-3
The Tumor invaded perinephric fat (code 1) and renal sinus fat (code2) thus assigned combination code 4
