Organization | Field Name | ID | Required |
|---|---|---|---|
KCR | Diag Confirmation Code (DiagConfirm) | 30470 | yes |
NAACCR | Diagnostic Confirm | yes |
Field Length: 1
Code | Label | Definition |
|---|---|---|
1 | Positive histology | Histologic confirmation (tissue microscopically examined). Microscopic diagnosis based on tissue specimens from biopsy, frozen section, surgery, autopsy, D&C, or from aspiration or biopsy of bone marrow specimens. |
2 | Positive cytology | Cytologic confirmation (fluid cells microscopically examined). Microscopic diagnosis based on examination of cells such as sputum smears, bronchial brushings or washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, peritoneal fluid, pleural fluid, urinary sediment, cervical or vaginal smears, or from paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid. |
4 | Positive microscopic confirmation, method not specified | Microscopic confirmation is all that is known. It is unknown if tissue or cells were examined. |
5 | Positive laboratory test/marker study | A clinical diagnosis of cancer based on laboratory tests/marker studies which are clinically diagnostic for cancer. Examples include AFP for liver cancer and abnormal electrophoretic spike for mulitple myeloma. Note: elevated PSA is only diagnostic of cancer if the physician uses the PSA as a basis for diagnosing prostate cancer with no further workup. |
6 | Direct visualization without microscopic confirmation | The tumor was visualized during a surgical or endoscopic procedure with no tissue resected for microscopic examination. Use this code when the diagnosis is based only on the surgeon's operative report from a surgical exploration or endoscopy, or from gross autopsy findings in the absence of tissue or cytological findings. |
7 | Radiography and other imaging techniques without microscopic confirmation | The malignancy was reported by the physician from an imaging technique report only. |
8 | Clinical diagnosis only | The malignancy was reported by the physician in the medical record. If a physician treats a patient for cancer, in spite of a negative biopsy, this is a reportable clinical diagnosis. Also, if a physician continues to describe a patient as having a reportable tumor, even after reviewing negative pathology results, this too is a reportable clinical diagnosis. |
9 | Unknown whether or not microscopically confirmed | A statement of malignancy was reported in the medical record, but there is no statement of how the cancer was diagnosed. |
Instructions for Diagnostic Confirmation for Coding Solid Tumors
1. The codes are in priority order; code 1 has the highest priority. Always code the procedure with the lower numeric value when presence of cancer is confirmed with multiple diagnostic methods.
2. Change to a higher-priority code, if at ANY TIME during the course of disease the patient has a diagnostic confirmation with a higher priority. Change to the higher-priority code even when diagnostic confirmation is based on the result of subsequent treatment.
Example: Benign brain tumor diagnosed on MRI. Assign diagnostic confirmation code 7. Patient later becomes symptomatic and the tumor is surgically removed. Change diagnostic confirmation code to 1.
3. Assign code 1 when the microscopic diagnosis is based on
a. Tissue specimens from fine needle aspirate, biopsy, surgery, autopsy, or D&C
b. Bone marrow specimens (aspiration and biopsy)
4. Assign code 2 when the microscopic diagnosis is based on
a. Examination of cells (rather than tissue) including but not limited to: sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, peritoneal fluid, pleural fluid, urinary sediment, cervical smears, or vaginal smears
b. Paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid
5. Assign code 4 when there is information that the diagnosis of cancer was microscopically confirmed, but the type of confirmation is unknown
6. Assign code 5 when the diagnosis of cancer is based on laboratory tests or tumor marker studies that are clinically diagnostic for that specific cancer and there is no other diagnostic work up (e.g., imaging)
Example: If the workup for a prostate cancer patient is limited to a highly elevated PSA (no DRE and no imaging) and the physician diagnoses and/or treats the patient based only on that PSA, code the diagnostic confirmation to 5.
Note: For tests and tumor markers that may be used to help diagnose cancer, see
https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis
https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/tumor-markers-fact-sheet
7. Assign code 6 when the diagnosis is based only on
a. The surgeon’s operative report from a surgical exploration or endoscopy such as colonoscopy, mediastinoscopy, or peritoneoscopy and no tissue was examined
b. Gross autopsy findings (no tissue or cytologic confirmation)
8. Assign code 7 when the only confirmation of malignancy was diagnostic imaging such as computerized axial tomography (CT scans), magnetic resonance imaging (MRI scans), or ultrasounds/sonography
Note: Intraductal papillary mucinous neoplasm with high grade dysplasia (8453/2) of the
pancreas is reportable based on imaging alone; histologic confirmation is not required.
9. Assign code 8 when the case was diagnosed by any clinical method not mentioned in preceding codes. The diagnostic confirmation is coded 8 when the only confirmation of disease is a physician’s clinical diagnosis.
Example: CT diagnosis is possible lung cancer. Patient returns to the nursing home with a Do Not Resuscitate (DNR) order. Physician enters a diagnosis of lung cancer in the medical record. Code the diagnostic confirmation to 8: there is a physician’s clinical diagnosis – clinical diagnosis made by the physician using the information available for the case.
10. Assign code 9
a. When it is unknown if the diagnosis was confirmed microscopically
b. For death certificate only case
Code | Label | Definition |
|---|---|---|
1 | Positive histology | Histologic confirmation (tissue microscopically examined). Microscopic diagnosis based on tissue specimens from biopsy, frozen section, surgery, autopsy, or bone marrow aspiration or biopsy. For leukemia only, code 1 when the diagnosis is based only on the complete blood count (CBC), white blood count (WBC), or peripheral blood (PB) smear. |
2 | Positive cytology | Cytologic confirmation (fluid cells microscopically examined). Microscopic diagnosis based on examination of cells such as spinal fluid, peritoneal fluid, pleural fluid, urinary sediment, cervical or vaginal smears, or from paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid. These methods are rarely used for hematopoietic or lymphoid tumors. |
3 | Positive histology PLUS positive immunophenotyping and/or positive genetic studies | Histology is positive for cancer, and there are also positive immunophenotyping and/or genetic test results. For example, bone marrow examination is positive for AML (9861/3). Genetic testing shows AML with inv(16)p13.1q22) (9871/3). Do not use this code for neoplasms diagnosed prior to January 1, 2010. |
4 | Positive microscopic confirmation, method not specified | Microscopic confirmation is all that is known. It is unknown if tissue or cells were examined. |
5 | Positive laboratory test/marker study | A clinical diagnosis of cancer is based on laboratory tests/marker studies which are clinically diagnostic for cancer. |
6 | Direct visualization without microscopic confirmation | The tumor was visualized during a surgical or endoscopic procedure only with no tissue resected for microscopic examination. Use this code when the diagnosis is based only on the surgeon's operative report from a surgical exploration or endoscopy, or from gross autopsy findings in the absence of tissue or cytological findings. |
7 | Radiography and other imaging techniques without microscopic examination | The malignancy was reported by the physician from an imaging technique report only. |
8 | Clinical diagnosis only | The malignancy was reported by the physician in the medical record. A number of hematopoietic and lymphoid neoplasms are diagnosed by tests of exclusion where the tests for the disease are equivocal and the physician makes a clinical diagnosis based on the information from the equivocal tests and the patient's clinical presentation. |
9 | Unknown whether or not microscopically confirmed | A statement of malignancy was reported in the medical record, but there is no statement of how the cancer was diagnosed. |
Instructions for Diagnostic Confirmation for Hematopoietic and Lymphoid Neoplasms (9590/3-9993/3)
See the Hematopoietic and Lymphoid Neoplasm Coding Manual and Database for coding instructions.
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