Scenario: 2023 abstracting case for St Elsewhere
Exam text: 75 YO Widowed White Female, Hispanic Presented with 2.5 cm lesion posterior right calf, no palpable inguinal lymphadenopathy, former smoker quit >10 years, no family history cancer, Height 64 inches Weight 125 lbs
05/30/2023 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
01/15/2023 Posterior right calf: punch bx @ St Elsewhere done by Dr Doe
05/30/2023 Wide local excision posterior right calf & sentinel lymph node biopsy (3 nodes removed) done by Dr Brooke at outside facility
01/15/2023 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
05/30/2023 at outside facility SENTINEL LYMPH NODE #1, RIGHT INGUINAL, EXCISIONAL BIOPSY: One lymph node, negative for metastatic melanoma (0/1).
SENTINEL LYMPH NODE #2, RIGHT FEMORAL GROIN, EXCISIONAL BIOPSY:
negative for metastatic melanoma (0/3).
SENTINEL LYMPH NODE #3, RIGHT FEMORAL GROIN, EXCISIONAL BIOPSY:
negative for metastatic melanoma (0/1).
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)
Question: How would you code the surgical procedures?
01/15/2023 B230-Punch Biopsy, NOS done at my facility St Elsewhere
05/30/2023 B530-Punch Biopsy followed by wide excision done at outside facility
Beginning in 2023 clinical melanoma margins will be coded from the operative report in the SSDI Clinical Margin Width. Margins are no longer part of the surgical code.
Another big change in 2023 is that shave, punch or elliptical biopsies are coded as surgical procedures no matter the margin status. You would only code a surgical diagnostic & staging procedure if there was just a tiny amount of tissue is taken, which should be a rare occurrence.
Refer to the STORE Manual v2023 Posted 6/28/2023 Appendix M: The CTR Guide to Coding Melanoma Cases in STORE v23 for more information.
Some Fields to consider:
|Date of Diagnosis||01/15/2023 [Date of Punch biopsy]|
|Date of First Contact||01/15/2023 [Date dx with melanoma at my facility]|
|Class of Case||13 [Punch bx surgery done at my facility, definitive surgery done elsewhere.]|
|Primary Site||C447 Skin Right Calf|
|SSDI Clinical Margin||1.5 [per Op note 1.5cm margin]|
|Histology||8743/3 Superficial Spreading Melanoma|
|Surgical Diagnostic and Staging Procedure||00 No surgical diagnostic or staging procedure was performed. [Remember 2023+ shave, punch or elliptical biopsies are coded as surgical procedures no matter the margin status.]|
|Date of First Surgical Procedure||01/15/2023 [Punch Biopsy]|
|Date of Most Definitive Surgical Resection of Primary Site||05/30/2023 [Wide Local Excision]|
|Rx Hosp-Surg 2023 [Surgery done at my facility]||B230 Punch Biopsy [That’ the most definitive surgery done at my facility St Elsewhere.]|
|RX Summ-Surg 2023 [Most definitive surgery done anywhere]||B530 Punch Biopsy followed by wide local excision [The most definitive surgery done anywhere.]|
|Scope of Regional Lymph Node Surgery||2 Sentinel Lymph Node Surgery|
|Date of SLN Biopsy||05/30/2023|
|# Positive SLN||00|
|# SLN examined||05|
|Date of Regional LN Dissection||BLANK [This fields documents the date non-sentinel regional node dissection, since the patient only had a SLN biopsy this field will be blank.]|
|Regional Lymph Nodes Positive||00|
|Regional Lymph Nodes Examined||05|
|AJCC Clinical Stage||cT1b cN0 cM0 Stage 1B|
|AJCC Path Stage||pT2a pN0 (sn) cM0 Stage 1B|