Tumor Tip of the Week 02-17-2023 Macroscopic Evaluation of the Mesorectum - Omega Healthcare

Tumor Tip of the Week 02-17-2023 Macroscopic Evaluation of the Mesorectum

Tumor Tip header image

Scenario: 2023 Rectal primary

Question:  How will you code Macroscopic Evaluation of the Mesorectum?

  • 00 Patient did not receive TME
  • 10 Incomplete TME
  • 20 Nearly Complete
  • 30 Complete TME
  • 40 TME performed not specified on pathology report as incomplete, nearly complete, or complete TME performed but pathology report not available Physician statement that TME performed, no mention of incomplete, nearly complete or complete status
  • 99 UNKNOWN if TME performed
  • BLANK Site not rectum (C20.9)

Answer & Rationale: 30 Complete TME

STORE Manual 2023

Macroscopic Evaluation of the Mesorectum required Status 2022+

This data item records whether a Total Mesorectal Excision (TME) was performed and the macroscopic evaluation of the completeness of the excision. Collect on all cases after implementation date regardless of date of diagnosis.

  • Information for this data item comes from the pathology report only
  • Codes 10, 20, and 30 must be based on pathology report

TIP:  For some reason, this facility did not record Macroscopic Evaluation of Mesorectum (required for rectal cancers) in the synopsis.  However, it was noted in the Gross Resection as Complete.  Be sure to read the entire path report, not just the final diagnosis or synopsis.  You should also bring this to the attention of the Pathology Department & Cancer Committee to make sure pathology is using the most current version of the CAP Approved Protocols and all data items are included.

Comments are closed.

Certificates of Compliance