READ THE NOTES IN THE SSDI MANUAL, NOT JUST THE DROP DOWNS!!!
New instructions in Version 2.1 (For use with cases diagnosed 2018 forward after conversion to the NAACCR v22 Layout)
Scenario: 2022
TAH, BSO unsuccessful lymph node mapping and comprehensive staging not performed given extensive intraperitoneal varicosities -Endometrial adenocarcinoma, endometrioid type limited to endometrium (30%) depth of myometrial invasion (FIGO Grade 2) Peritoneal cytology not done
Med Onc: FIGO Stage 1A
Question: How would you code the SSDI’s?
| SSDI | Code | Rationale-SSDI Manual v2.1 |
| FIGO Stage | 1A | Note 1: Take the highest Federation Internationale de Gynecologie et d’Obstetrique (FIGO) stage documented in the medical record. Do not attempt to code FIGO stage based only on T, N, and M. If FIGO stage is not documented in the medical record, code 99. FIGO stage is not the same as FIGO grade.Only code FIGO stage in this field, do not code FIGO grade. |
| Number of Positive Pelvic Nodes | X9 | Note 6: Code X9 if no lymph node dissection is performed. If only a FNA or core biopsy is done and it is positive, then code X6 If only a FNA or core biopsy is done and it is negative, then code X9 Code X9 when no lymph nodes are removed |
| Number of Examined Pelvic Nodes | 00 | Note 4: For the following Code 00 when no lymph nodes are examined by FNA, core biopsy or removal of lymph node(s) (e.g., sentinel lymph node biopsy or lymph node dissection) Code X6 If only a FNA or core biopsy is done Code X9 if it’s unknown if lymph nodes were removed |
| Number of Positive Para-Aortic Nodes | X9 | Note 6: Code X9 if no lymph node dissection is performed. If only a FNA or core biopsy is done and it is positive, then code X6 If only a FNA or core biopsy is done and it is negative, then code X9 Code X9 when no lymph nodes are removed |
| Number of Examined Para-Aortic Nodes | 00 | Note 4: For the following Code 00 when no lymph nodes are examined by FNA, core biopsy or removal of lymph node(s) (e.g., sentinel lymph node biopsy or lymph node dissection) Code X6 If only a FNA or core biopsy is done Code X9 if it’s unknown if lymph nodes were removed |
| Peritoneal Cytology | 9 | Not documented in patient record Peritoneal cytology not assessed or unknown if assessed |