Just as important as it is to code the treatment a patient received, you also need to code when a treatment is not given due to various reasons, like contraindicated, patient expired, patient refused, or recommended but unknown if done- be sure to follow up on those cases. It is important to document why standard of care was not given. Below are examples of various scenarios.
| Scenario | Question | Answer | Rationale & Discussion |
| pT2 pN0 cM0 Stage 1 Thyroid Ca
Med Onc-Given size of the tumor of 3.7 cm and proximity to edge of thyroid gland we discussed that she may benefit from RAI [radioactive iodine] We will plan to do remnant ablation with RAI
At time of abstracting, no further info available.
|
How would you code Reason for No Radiation? | 8 Radiation therapy was recommended, but it is unknown whether it was administered | STORE/SEER Program Coding & Staging Manual – Code 8 If it is known that a physician recommended radiation treatment, but no further documentation is available to confirm it was given.
Note: Cases coded 8 should be followed and updated to a more definitive code as appropriate.
|
| cT1 cN0 cM0 Stage 1 Endometrial cancer-recommended to have TAH/BSO but expired prior to surgery being given. | How would you code Reason for No Surgery of Primary Site? | 5 Surgery of the primary site was not performed because the patient died prior to planned or recommended surgery. | STORE/SEER Program Coding & Staging Manual –
Code 5 If Surgery of the primary site was not performed because the patient died prior to planned or recommended surgery. |
| cT3 cN0 cM0 Colon Cancer
Med Onc- Patient doesn’t want any form of chemotherapy, daughters all agree.
|
How would you code Chemotherapy? | 87
Chemotherapy was not administered. It was recommended by the patient’s physician, but this treatment was refused by the patient, a patient’s family member, or the patient’s guardian. The refusal was noted in patient record. |
STORE/SEER Program Coding & Staging Manual
Assign code 87 when
|
| Patient dx with cancer NCCN guidelines for this site/ histology/ stage of cancer are Surgery/ followed by Chemo+ Radiation+ Immunotherapy. Patient refused all further workup and treatment before any recommendations could be made. | How would you Code
Reason No Srg Reason No Xrt Chemo Immunotherapy |
Rsn No Srg-7 Refused
Rsn No Xrt 7 Refused Chemo 87 Refused Immunotherapy 87 Refused |
STORE/SEER Program Coding & Staging Manual
Assign code 87 when
|
| cT1a cN1 cM0 Lung Cancer
Med Onc- need adjuvant therapy Carboplatin/ pemetrexed followed by immunotherapy w/ pembrolizumab or atezolizumab
At time of abstracting, no further info available.
|
How would you code Chemotherapy?
How would you code Immunotherapy? |
88 Chemotherapy was recommended, but it is unknown if it was administered
88 Immunotherapy was recommended, but it is unknown if it was administered
|
STORE/SEER Program Coding & Staging Manual
Assign code 88 when
Note: Review cases coded 88 periodically for later confirmation of chemotherapy /immunotherapy therapy. |
| Multiple Myeloma
Med Onc. Treated with daratumumab CyBorD … Patient has responded well to treatment. She will be referred for evaluation of autologous bone marrow transplant with the bone marrow transplant team.
Transplant Team- Overall poor KPS and Frailty assessment consistent with FRAIL state and overall high medium risk for high-risk interventions. In addition to other comorbid conditions including GI and pulmonary and age would disqualify her from Bone Marrow Transplant.
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How would you code Hematologic Transplant and Endocrine Procedures? | 82
Hematologic transplant and/or endocrine surgery/radiation was not recommended/administered because it was contraindicated due to patient risk factors (i.e., comorbid conditions, advanced age, progression of disease prior to administration, etc.). |
STORE/SEER Program Coding & Staging Manual
Code 82 If Transplant procedure and/or endocrine therapy was not recommended/administered because it was contradicted due to patient risk factors (i.e., comorbid conditions, advanced age, progression of tumor prior to planned administration, etc.) |
*Refer to Software Vendor for Instructions on the proper way to code 82-88, so the export is correct.