Scenario: 2024
- Operative Text:
- 01/30/2024 Outside facility Dr Brooke: Right inguinal sentinel lymph node biopsy x5, Wide local excision of posterior right calf melanoma- The primary melanoma lesion was about 3 cm x 2 cm lesion excised with 1.5 cm margin
- Surgery Text:
- 01/15/2024 Posterior right calf: punch bx @ St Elsewhere done by Dr Doe
- 01/30/2024 Wide local excision posterior right calf & sentinel lymph node biopsy (3 nodes removed) done by Dr Brooke at outside facility
- Path Text:
- 01/15/2024 at St Elsewhere: posterior right calf: punch bx: superficial spreading malignant melanoma, measuring 1.0 mm in depth, Breslow thickness: 1.0 mm, mitotic rate: less than 1 mitosis/mm2, no ulceration
- 01/30/2024 at outside facility: SKIN, RIGHT CALF, WIDE EXCISION: Melanoma, Histologic type: Superficial spreading Breslow thickness: 1.7 mm, Ulceration: Not identified, Mitotic rate: 1/mm² Margins negative
(10 mm from all margins) LVI: Negative 3 SLN from right inguinal & right femoral groin (-)
Question: How would you assign SSN Clinical Margin Width?
- 1.5 [from the operative report]
- 1.0 [10 mm (which is equivalent to 1cm) from path report]
Answer: 1.5 the measurement of the margin from the Operative report
SSDI Manual Clinical Margin Width –
Note 3: Code the peripheral surgical margins from the operative report from a wide excision
Do not use the pathology report to code this data item.
Refer to STORE 2024 release date 1/23/2024, Appendix M of The CTR Guide to Coding Melanoma Cases in STORE for more examples of how to code various melanoma scenarios.
Make sure you are looking at the most recent release date for STORE 2024, 01-23-2024, this was a change made to the coding of SSDI Clinical Margin in Example#8 in Appendix M of The CTR Guide to Coding Melanoma Cases in STORE.
