Cytology is an 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. It can also be paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid.
Does cytology confirmation alone constitute a reportable case?
Here are my thoughts…
A positive cytology makes cancer a reportable case. Diagnostic Confirmation is coded as Code 2 – positive cytology. If the cytology date is the earliest date that confirms the diagnosis, code the cytology date as the Date of Diagnosis.
What if the cytology report is preceded by an ambiguous terminology, is this reportable?
Example 1: Thoracentesis reveals “malignant appearing” cells.
Example 2: Peritoneal fluid cytology “suspicious” malignant cells.
If a cytology is identified only with an ambiguous term, do not interpret it as a diagnosis of cancer. The case should not be accessioned based on ambiguous cytology. Abstract the case only if a positive histology follows the cytology, or a physician’s clinical impression of cancer supports the cytology findings, or if a physician proceeds to treat the patient.
What will be your Date of Diagnosis? The date of ambiguous cytology should not be used as the Date of Diagnosis even when proven to be a malignancy at a later date. Use the date of the first positive histology, the date the physician clinically first diagnosed it as a cancer, or the date of first cancer-directed treatment.
The Diagnostic Confirmation will be coded to Code 1 if positive histology or Code 8 if clinical diagnosis only and/or cancer-directed treatment is administered.
Initial imaging reveals lung mass. No diagnostic confirmation.
6-2-2012 Thoracentesis reveals “malignant appearing” cells.
No further work-up done.
8-2-2012 Physician proceeds with cancer-directed treatment.
Date of Diagnosis: 8-2-2012
Diagnostic Confirmation: Code 8 – Clinical diagnosis only.
What are your thoughts?