03-22-2024 Definitive Statement of Diagnosis
Scenario:
- 3/1/2024 CT Abdomen/Pelvis-8 cm solid mass in the right kidney with renal vein invasion. Multiple osseous
metastases of the spine and pelvis including a large paraspinal/vertebral metastasis centered at T10.
- 3/2/2024 Med Onc Consult: 68 yo M with kidney mass and osseous lesions most likely renal primary
- 3/3/2024 thoracic tumor resection-Metastatic Clear Cell Renal Cell Carcinoma w/ bone invasion
- 3/5/2024 -03/19/2024 Palliative T-spine 300 x 10 fxs total 3000 cGy
Question: What is the date of diagnosis?
- 3/1/2024-Date of Scan that states Multiple osseous metastases of the spine and pelvis
- 3/2/2024 Date Physician used ambiguous terminology that constitutes a diagnosis “Most Likely Renal Primary”
- 3/3/2024 Date of positive biopsy
Answer: 3/1/2024
Rationale: Sometimes we see abstractors choose the date of diagnosis when one of those ambiguous terms is used, but you must be careful. On 3-1-2024 the scan states the patient has metastatic disease, that is not ambiguous, it is a definitive statement. So, you don’t have to refer to that “Ambiguous Terms” section in the manuals, you would use the date of 3-1-2024 as the date of diagnosis when the patient was clinically established to have metastatic disease.