16.2 Surgery Coding: Rx Summ–Surg 2023 [1291], Lymph Node Surgery [1292], Other Site [1294], Margins & Reason for No Surgery
Key Takeaways
Rx Summ–Surg 2023 [1291] uses 4-character codes for 2023+ diagnoses; codes start with A, except skin, colon, pancreas, lung, breast and thyroid, which use B-prefixed codes to signal a significant coding change.
Surgery codes record the most invasive, cumulative procedure: a lumpectomy followed by a total mastectomy is coded as the mastectomy, and an excisional biopsy that removes the whole tumor or leaves only microscopic margins is surgery, not a diagnostic procedure.
Special codes: A000/B000 none (also for autopsy diagnosis), A980 for sites such as C420–C424, C760–C768 and C809, A900/B900 surgery NOS, and A990/B990 unknown or death certificate only.
Scope of Regional LN Surgery [1292] is hierarchical and cumulative (0–7, 9): a sentinel biopsy followed later by a dissection is 7; the operative report, not the node count, distinguishes sentinel biopsy from dissection.
Surgical Margins [1320] codes 0–3 are hierarchical (0 none, 1 residual NOS, 2 microscopic, 3 macroscopic), 7 is not evaluable, 8 is no primary site surgery, and 9 is unknown.
How the surgery items fit together
| Item | Records |
|---|---|
| Rx Summ–Surg 2023 [1291] | Most invasive surgery of the primary site, including tissue removed in continuity (at any facility) |
| Rx Hosp–Surg 2023 [671] | The same item, limited to surgery at the reporting facility |
| Scope of Regional Lymph Node Surgery [1292] | Removal, biopsy or aspiration of regional nodes (sentinel or dissection) |
| Surgical Procedure/Other Site [1294] | Resection of distant nodes, or of regional or distant tissue or organs beyond the primary site range |
| Surgical Margins of the Primary Site [1320] | Final margin status after primary site surgery |
| Reason for No Surgery of Primary Site [1340] | Why primary site surgery was not done |
| Date of First Surgical Procedure [1200] | First of 1291, 1292 (excluding code 1) or 1294 |
| Date of Most Definitive Surgical Resection [3170] | Date of the most definitive primary site surgery |
| Readmission Within 30 Days of Surgical Discharge [3190] | Quality item for unplanned readmission |
If multiple primaries are treated in one operation, code the surgery items separately for each primary. Incidental removal of an organ (for example, an appendix during a right colectomy, or a gallbladder removed for another reason) does not change the codes.
Rx Summ–Surg 2023 [1291]
- Diagnosis years: this item is used for 2023+. Earlier cases use Surgical Procedure of Primary Site [1290], and 1291 is left blank.
- Prefix: codes begin with A, except skin, colon, pancreas, lung, breast and thyroid, which use B codes to mark a significant change in coding. The site-specific codes are in Appendix A.
| Code range | Meaning |
|---|---|
| A000 / B000 | None; also used when the cancer was diagnosed at autopsy |
| A100–A190 / B100–B190 | Tumor destruction, with no pathology specimen (for example, ablation) |
| A200–A800 / B200–B800 | Resection procedures, from local excision to radical surgery |
| A900 / B900 | Surgery, NOS |
| A980 | Special code for sites such as C420, C421, C423, C424, C760–C768 and C809 (heme, ill-defined, unknown primary). Use item 1294 to show whether surgery was done |
| A990 / B990 | Unknown if surgery was done; death certificate only |
Rules
- Hierarchical: within A000/B000–A790/B790, codes listed later take precedence. Use the 800 and 900 codes only when more precise information is missing.
- Cumulative: when a later procedure removes the rest of the primary site, code the total or final result. For example, a lumpectomy, then re-excision, then total mastectomy is coded as the mastectomy. Do not rely on software to accumulate.
- Excisional biopsy: an excisional biopsy that removes the entire tumor or leaves only microscopic margins is coded here. A needle biopsy followed by an excision stays a needle biopsy in Surgical Diagnostic and Staging Procedure [1350] (Section 10.1).
- Regional tissue is included only if it was removed in continuity with the primary, unless Appendix A says otherwise.
- Palliative surgery is also recorded in Palliative Care [3270].
Breast (C50, 2024+ B-codes)
| Code | Procedure |
|---|---|
| B200 | Partial mastectomy (lumpectomy, segmental, quadrantectomy), after a previous positive biopsy |
| B210 | Excisional biopsy that diagnosed the cancer, with no pre-operative biopsy proving cancer |
| B215 | Excisional biopsy for atypia (for example, ADH on core biopsy) that finds cancer |
| B240 | Re-excision of margins when less than a total mastectomy is done |
| B290 | Central lumpectomy including the nipple-areolar complex |
| B300 / B400 / B500 | Skin-sparing / nipple-sparing / areolar-sparing mastectomy (x10 without, x20 with removal of the uninvolved contralateral breast) |
| B600 | Total (simple) mastectomy. STORE says to use B600 for a modified radical mastectomy |
| B700 | Radical mastectomy, which removes the pectoralis muscle, with a level I–III axillary dissection. B760 is a bilateral mastectomy for one tumor involving both breasts (for example, bilateral inflammatory carcinoma) |
| B800 / B900 | Mastectomy NOS / surgery NOS |
Breast reconstruction is recorded in separate reconstruction items, not in 1291.
Colon (C18, B-codes)
| Code | Procedure |
|---|---|
| B100 | Local tumor destruction (electrocautery, fulguration) |
| B200–B291 | Local excision, including B280 endoscopic polypectomy, B281 endoscopic mucosal resection or dissection, and B291 wide local excision |
| B300 | Partial colectomy: one or more segments but less than half of the colon |
| B400 | Hemicolectomy: the total right or left colon plus part of the transverse colon (including extended hemicolectomy). B401 is subtotal colectomy |
| B500 | Total colectomy (cecum to the rectosigmoid) |
| B600 | Total proctocolectomy |
| B700 | Colectomy with en bloc resection of contiguous organs, NOS |
Removing liver metastases during colon surgery is coded in Surgical Procedure/Other Site [1294], not in 1291.
Scope of Regional Lymph Node Surgery [1292]
| Code | Meaning |
|---|---|
| 0 | None |
| 1 | Biopsy or aspiration of regional node(s) |
| 2 | Sentinel lymph node biopsy (SLNB) |
| 3 | Number of regional nodes removed unknown or not stated; regional node surgery, NOS |
| 4 | 1–3 regional nodes removed |
| 5 | 4 or more regional nodes removed |
| 6 | SLNB and code 3, 4 or 5 at the same time, or timing not stated |
| 7 | SLNB and code 3, 4 or 5 at different times |
| 9 | Unknown or not applicable (for example C420–C424, C589, brain and CNS, C761–C768, C770–C779, C809) |
- Codes 0–7 are hierarchical and cumulative. A SLNB followed weeks later by a completion dissection is 7.
- The operative report is the primary source for distinguishing SLNB from a dissection. Do not use the number of nodes examined alone. The 4-versus-5 split exists for comparison with historical data and is not a quality judgment.
- Distant nodes removed at surgery go in item 1294.
- For breast and melanoma, sentinel node dates and counts are recorded in their own items: Date of Sentinel Lymph Node Biopsy [832], Sentinel Lymph Nodes Examined [834] and Positive [835].
Regional Nodes Examined [830] and Positive [820]
- Examined: 00 none; 01–89 exact number; 90 = 90 or more; 95 aspiration only; 96 documented as a sampling, number unknown; 97 documented as a dissection, number unknown; 98 nodes removed, number unknown; 99 unknown.
- Positive uses parallel codes. Nodes with only isolated tumor cells are not counted as positive, except for cutaneous melanoma and Merkel cell carcinoma (Section 15.3).
- Resolve count discrepancies in this order: final diagnosis, synoptic report, microscopic, gross (Section 10.2).
Surgical Procedure/Other Site [1294]
Codes: 0 none; 1 non-primary surgery, unknown if regional or distant; 2 other regional site; 3 distant lymph node(s); 4 distant site; 5 combination of 2, 3 and 4; 9 unknown.
- Code 1 for the special sites (C420–C424, C760–C768, C770–C779, C809) when non-primary surgery was done.
- Incidental removal is 0.
Surgical Margins of the Primary Site [1320]
| Code | Meaning |
|---|---|
| 0 | No residual tumor: all margins grossly and microscopically negative |
| 1 | Residual tumor, NOS |
| 2 | Microscopic residual tumor |
| 3 | Macroscopic (gross) residual tumor |
| 7 | Margins not evaluable |
| 8 | No primary site surgery (also for autopsy diagnosis) |
| 9 | Unknown; no mention of margins; A980 cases; special sites; DCO |
- Codes 0–3 are hierarchical: if the proximal margin is grossly involved and the distal margin microscopically involved, code 3.
- Record the final margin status after all primary site surgery. For example, a re-excision that clears a positive lumpectomy margin gives 0.
Reason for No Surgery of Primary Site [1340]
| Code | Meaning |
|---|---|
| 0 | Surgery of the primary site was performed |
| 1 | Not performed because it was not part of the planned first course |
| 2 | Contraindicated because of patient risk factors (comorbidities, advanced age, progression) |
| 5 | Patient died before planned surgery |
| 6 | Recommended, not performed, no reason documented |
| 7 | Recommended but refused by the patient, family member or guardian |
| 8 | Recommended, unknown if performed. Follow it up |
| 9 | Unknown if recommended or performed; DCO |
Worked examples
- A core biopsy shows carcinoma, then a lumpectomy with close but negative margins and a SLNB (2 nodes, both negative): 1291 = B200, 1292 = 2, 1320 = 0, 830 = 02, 820 = 00, 1350 = 02.
- An endoscopic polypectomy shows carcinoma with a positive margin, followed by a laparoscopic sigmoidectomy with 16 nodes removed: 1291 = B300 (cumulative, final result), 1292 = 5, 830 = 16.
- A patient with lung cancer and severe COPD is judged too frail for resection and receives SBRT: 1340 = 2, and 1291 = B000.
A patient with invasive breast carcinoma has a sentinel lymph node biopsy during her lumpectomy. Two weeks later, because a sentinel node was positive, she has a completion axillary dissection with 11 more nodes removed. How is Scope of Regional Lymph Node Surgery [1292] coded?
2
5
6
7
A 2026 breast cancer patient has a modified radical mastectomy, with no removal of the contralateral breast. Which Rx Summ–Surg 2023 code applies?
B700
B600 (or its subcategory B610)
B800
B400
A colon resection report states the proximal margin is grossly involved by tumor and the distal margin shows microscopic involvement. How is Surgical Margins of the Primary Site [1320] coded?
1
2
3
7
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