- Presented to ER w/ testicular pain swelling. Physical Exam: Large fixed mass left testicle, No lymphadenopathy appreciated
- US Scrotum: 0.5cm area in the left testicle suspicious for neoplasm
Question: How would you code the primary site?
- 0 Undescended testis
- 1 Descended testis
- 9 Testis, Nos
Answer & Rationale:
SEER Inquiry System – Question 20140005
Question: Primary site–Testis: In the absence of a specific statement that the patient’s testicle(s) are descended, should the primary site for a testicular tumor be coded as C621 (Descended Testis) when the mass is palpable on physical exam or demonstrated on scrotal ultrasound? See discussion.
Discussion: It seems the non-specific Testis, NOS (C629) code is being over-used. Many testis cases have no documentation of the patient’s testicular descension. However, testicular tumors in adults are frequently detected by palpation or scrotal ultrasound. An undescended testis (a testis absent from the normal scrotal position) would be non-palpable or not amenable to imaging via a scrotal ultrasound.
Answer: Unless the testicle is stated to be undescended, it is reasonable to code C621 for primary site. Reserve C629 for cases with minimal or conflicting information.