Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

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Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site SINGLE TUMOR: IN SITU ONLY (Single Tumor; all parts are in situ) H1 The pathology/cytology 1: Priority for using documents The histology report is not available to code the histology documented by the Documentation in the physician medical record that refers to pathologic or cytologic findings Physician’s reference to type of cancer (histology) in the medical record 2: Code the specific histology when documented. 3: Code the histology to 8000 (cancer/malignant neoplasm, NOS) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented H2 One type Do not code terms that do not The histology appear in the histology description. Example: Do not code squamous cell carcinoma non-keratinizing unless the words “non- keratinizing” actually appear in the diagnosis.

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Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H3 The final diagnosis is It is important to know that the 8210 Adenocarcinoma in adenocarcinoma originated in a (adenocarcinoma in a polyp or polyp adenomatous polyp) Adenocarcinoma or and a residual polyp 8261 or polyp architecture (adenocarcinoma in is recorded in other villous adenoma) or parts of the 8263 pathology report. (adenocarcinoma in Adenocarcinoma tubulovillous and there is adenoma) reference to a residual or pre- existing polyp or Mucinous/colloid or signet ring cell adenocarcinoma in a polyp or There is documentation that the patient had a polypectomy

Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H4 Carcinoma in situ, The specific histology may be The most specific NOS (8010) and a identified as type, subtype, histologic term specific in situ predominantly, with features of, carcinoma or major, or with ____ differentiation, architecture or Squamous cell pattern. The terms architecture carcinoma in situ, and pattern are subtypes only for NOS (8070) and a in situ cancer. specific in situ squamous cell carcinoma or Adenocarcinoma in situ, NOS (8140) and a specific in situ adenocarcinoma or Melanoma in situ, NOS (8720) and a specific in situ melanoma H5 Multiple specific The specific histology may be The appropriate histologies or identified as type, subtype, combination/ mixed A non-specific predominantly, with features of, code (Table 2) major, or with histology with ____differentiation, architecture multiple specific or pattern. The terms architecture histologies and pattern are subtypes only for in situ cancer. H6 None of the above conditions are met The numerically higher ICD-O-3 code

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site SINGLE TUMOR: INVASIVE AND IN SITU (Single Tumor; in situ and invasive components) H7 Invasive This is a change from the The single invasive and in situ previous histology coding rules histology. Ignore the and is different from ICD-O-3 in situ terms. rules. This change was made in collaboration with the ICD-O-3 editors. The consensus was that coding the invasive component of the tumor better explains the likely disease course and survival category. SINGLE TUMOR: INVASIVE ONLY (Single Tumor; all parts are invasive) H8 No pathology/cytology 1: Priority for using documents The histology specimen or the to code the histology documented by the pathology/cytology report Documentation in the physician is not available medical record that refers to pathologic or cytologic findings Physician’s reference to type of cancer (histology) in the medical record CT, PET or MRI scans 2: Code the specific histology when documented 3: Code the histology to 8000 (cancer/malignant neoplasm, NOS) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented H9 None from primary site Code the behavior /3 The histology from a metastatic site Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H10 Prostate Acinar 8140 (adeno)carcinoma (adenocarcinoma NOS) H11 One type 1: Do not code terms that do not The histology appear in the histology description. Example: Do not code squamous cell carcinoma non-keratinizing unless the words “non- keratinizing” actually appear in the diagnosis. 2: If this is a papillary carcinoma of the thyroid, go to Rule H14. H12 Final diagnosis is: It is important to know that the 8210 Adenocarcinoma in adenocarcinoma originated in a (adenocarcinoma in a polyp or polyp adenomatous polyp) Adenocarcinoma or and a residual polyp 8261 or polyp architecture (adenocarcinoma in is recorded in other villous adenoma) or parts of the 8263 pathology report or (adenocarcinoma in Adenocarcinoma and there is tubulovillous reference to a adenoma) residual or pre- existing polyp or Mucinous/colloid or signet ring cell adenocarcinoma in a polyp or There is documentation that the patient had a polypectomy

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H13 Cancer/malignant The specific histology may be The most specific neoplasm, NOS identified as type, subtype, histologic term (8000) and a more predominantly, with features of, specific histology or major, or with ____differentiation. The terms Carcinoma, NOS architecture and pattern are (8010) and a more subtypes only for in situ cancer. specific carcinoma Example 1: Adenocarcinoma, or predominantly mucinous. Code Squamous cell mucinous adenocarcinoma carcinoma, NOS (8480). (8070) and a more Example 2: Non-small cell specific squamous carcinoma, papillary squamous cell carcinoma or cell. Code papillary squamous cell carcinoma (8052). Adenocarcinoma, NOS (8140) and a more specific adenocarcinoma or Melanoma, NOS (8720) and a more specific melanoma or Sarcoma, NOS (8800) and a more specific sarcoma H14 Thyroid Papillary carcinoma 8260 (papillary adenocarcinoma, NOS) H15 Thyroid Follicular and papillary 8340 (Papillary carcinoma carcinoma, follicular variant)

Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H16 Multiple specific The specific histology may be The appropriate histologies or identified as type, subtype, combination code A non-specific predominantly, with features of, (Table 2) major or with _____ histology with differentiation. multiple specific Example 1 (multiple specific histologies histologies): Mucinous and papillary adenocarcinoma. Code 8255 (adenocarcinoma with mixed subtypes). Example 2 (multiple specific histologies): Combined small cell and squamous cell carcinoma. Code 8045 (combined small cell carcinoma) Example 3 (non-specific with multiple specific histologies): Adenocarcinoma with papillary and clear cell features. Code 8255 (adenocarcinoma with mixed subtypes) H17 None of the above conditions are met The numerically higher ICD-O-3 code

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site MULTIPLE TUMORS ABSTRACTED AS A SINGLE PRIMARY H18 No pathology/cytology 1: Priority for using documents The histology specimen or the to code the histology documented by the pathology/cytology report Documentation in the medical physician is not available record that refers to pathologic or cytologic findings Physician’s reference to type of cancer (histology) in the medical record CT, PET or MRI scans 2: Code the specific histology when documented 3: Code the histology to 8000 (cancer/malignant neoplasm, NOS) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented H19 None from primary site Code the behavior /3 The histology from a metastatic site H20 Prostate Acinar 8140 (adeno)carcinoma (adenocarcinoma NOS) H21 Sites such Squamous In situ 1: VIN, VAIN, and AIN are 8077/2 (Squamous as: intraepithelial neoplasia squamous cell carcinomas. Code intraepithelial Vulva grade III such as: 8077 cannot be used for glandular neoplasia, grade III) Vagina vulva (VIN III) intraepithelial neoplasia such as Anus prostatic intraepithelial neoplasia vagina (VAIN III) (PIN) or pancreatic intraepithelial anus (AIN III). neoplasia (PAIN). 2: This code may be used for reportable-by-agreement cases

Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H22 Sites such Glandular In situ This code may be used for 8148/2 (Glandular as: intraepithelial neoplasia reportable-by-agreement cases intraepithelial Pancreas grade III such as: such as intraepithelial neoplasia neoplasia grade III) pancreas (PAIN III) of the prostate (PIN III)

H23 One type Do not code terms that do not The histology appear in the histology description. Example: Do not code squamous cell carcinoma non-keratinizing unless the words “non- keratinizing” actually appear in the diagnosis. H24 Anus Extramammary Paget The histology of the Perianal disease and an underlying tumor region underlying tumor Vulva

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H25 Final diagnosis is: It is important to know that the 8210 Adenocarcinoma in adenocarcinoma originated in a (adenocarcinoma in a polyp or polyp adenomatous polyp) Adenocarcinoma or and a residual polyp 8261 or polyp architecture (adenocarcinoma in is recorded in other villous adenoma) or parts of the 8263 pathology report or (adenocarcinoma in Adenocarcinoma tubulovillous and there is adenoma) reference to a residual or pre- existing polyp or Mucinous/colloid or signet ring cell adenocarcinoma in a polyp or There is documentation that the patient had a polypectomy H26 Thyroid Papillary carcinoma 8260 (papillary adenocarcinoma, NOS) H27 Thyroid Follicular and papillary 8340 (Papillary carcinoma carcinoma, follicular variant)

Other Sites Histology Coding Rules – Matrix Excludes Head and Neck, Colon, Lung, Melanoma, Breast, Kidney, Renal Pelvis, Ureter, Bladder, Brain, Lymphoma and Leukemia

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H28 Invasive This is a change from the The single invasive and in situ previous histology coding rules histology. Ignore the and is different from ICD-O-3 in situ terms rules. This change was made in collaboration with the ICD-O-3 editors. The consensus was that coding the invasive component of the tumor better explains the likely disease course and survival category. H29 Cancer/malignant The specific histology may be The most specific neoplasm, NOS identified as type, subtype, histologic term (8000) and a more predominantly, with features of, specific histology or major, or with ____differentiation. The terms Carcinoma, NOS architecture and pattern are (8010) and a more subtypes only for in situ cancer. specific carcinoma Example1: Adenocarcinoma, or predominantly mucinous. Code Squamous cell mucinous adenocarcinoma carcinoma, NOS (8480). (8070) and a more Example 2: Non-small cell specific squamous carcinoma, papillary squamous cell carcinoma or cell. Code papillary squamous cell carcinoma (8052). Adenocarcinoma, NOS (8140) and a more specific adenocarcinoma or Melanoma, NOS (8720) and a more specific melanoma or Sarcoma, NOS (8800) and a more specific sarcoma

Rule Pathology/Cytology Primary Histology Behavior Notes and Examples Code Specimen Site H30 Multiple specific The specific histologies may be The appropriate histologies or identified as a type, subtype, combination/mixed A non-specific predominantly, with features of, code (Table 2) histology with multiple major, or with ____ specific histologies differentiation. Example 1 (multiple specific histologies): Gyn malignancy with mucinous, serous and papillary adenocarcinoma. Code 8323 (mixed cell adenocarcinoma) Example 2 (multiple specific histologies): Combined small cell and squamous cell carcinoma. Code 8045 (combined small cell carcinoma). Example 3 (non-specific with multiple specific histologies): Adenocarcinoma with papillary and clear cell features. Code 8255 (adenocarcinoma with mixed subtypes) H31 None of the above conditions are met The numerically higher ICD-O-3 code