09-27-2024 SSDI Ipsilateral Adrenal Gland Involvement
| Situation | Scenario | SSDI Ipsilateral Gland Involvement | Answer & Rationale |
| Confined to the Kidney | Patient has a Partial Nephrectomy, and adrenal gland was not removed. Pathology report states clear cell adenocarcinoma, tumor is limited to the kidney. | 0
Ipsilateral adrenal gland involvement not present/not identified |
SSDI Manual Note 2. If surgical resection is done and the tumor is “confined to kidney” and staging is based on size, then there is no involvement of the adrenal gland |
| Invasion beyond the Kidney | Patient has a Total Nephrectomy, and adrenal gland was not removed. Pathology report states clear cell adenocarcinoma, invasion into renal sinus | 9
Not documented in medical record Ipsilateral adrenal gland not resected |
SSDI Manual Note 5: Code 9 if surgical resection of the primary site is performed and there is no mention of ipsilateral adrenal gland involvement. |
| No Surgical Resection | CT scan: Kidneys: solid mass in the right kidney involving the inferior pole calices with extension to the pelvis. Measures 2.3 x 2.3 x 2.7 cm. Does not extend beyond the renal cortex into the perirenal space. No renal vein invasion. Left kidney is normal. Adrenal Glands: Unremarkable.
Patient refused surgery. |
9
No surgical resection of primary site is performed |
SSDI Manual Note 3: Record ipsilateral adrenal gland involvement as documented in the pathology report.
Note 4: Do not use imaging findings to code this data item. |