Reason No Therapy (Surg)

Field Length:  1

Using the codes below, record the reason there was no cancer-directed Surgery of the Primary Site as part of first course treatment.

Coding Instructions

1.  Assign code 0 when Surgery of Primary Site is coded in the range of 10-90 (surgery of the primary site was performed)
2.  Assign a code in the range of 1-8 if Surgery of Primary Site is coded 00 or 98
   Note: Referral to a surgeon is equivalent to a recommendation for surgery.
   1. Assign code 1 when
      1. There is no information in the patient’s medical record about surgery, AND
      2. It is known that surgery is not usually performed for this type and/or stage
         of cancer
         OR
      3. There is no reason to suspect that the patient would have had surgery of primary site

Example: The patient would not be a surgical candidate because of advanced stage.
ii. The treatment plan offered multiple treatment options and the patient selected treatment that did not include surgery of the primary site
Example: Prostate cancer patient is offered three treatment options: a. Radical prostatectomy, b. Radiation therapy, or c. Hormone therapy. The patient chose to have radiation therapy. Assign code 1. Surgery of the primary site was not performed because it was not part of the planned first course of treatment. The treatment plan was for the patient to receive ONE of three treatment modality options: surgery, OR radiation, OR hormone therapy. At no time did the physician recommend that the patient have surgery AND radiation therapy AND hormone therapy. The patient chose radiation. This does not mean he refused surgery
because at no time did the treatment plan include both radiation AND surgery. Recording that a patient refused the treatment modality means that the patient refused recommended therapy. This is a quality control check explaining why the patient did not receive the expected treatment for their cancer (patient’s choice versus physician’s choice, or facility’s lack of providing quality care). 

iii. Patient elected to pursue no treatment following the discussion of surgery. Discussion does not equal a recommendation. Patient's decision not to pursue surgery is not a refusal of surgery in this situation. 

iv. Active surveillance/watchful waiting is the first course (e.g., prostate) 

b. Assign code 6 when
      i. It is KNOWN that surgery was recommended
      AND
      ii. It is KNOWN that surgery was not performed
      AND
      iii. There is no documentation explaining why surgery was not done    

Example: The medical record has a recommendation that the patient have surgery. No further admissions or documentation of surgery found; the primary care physician replies that the patient did NOT have surgery. No further information is given; it is unknown if the patient refused surgery or if there were co-morbid conditions that prevented the surgical procedure.

c. Assign code 7 when the patient

i. Refuses recommended surgery
     OR
ii. Makes a blanket statement that he/she refused all treatment when surgery is a customary option for the primary site/histology
           • Assign code 1 when surgery is not normally performed for the site/histology

Note: Coding Reason for No Surgery of Primary Site as “refused” does not affect the coding of the other      treatment fields (e.g., Radiation, Chemotherapy, Hormone Therapy, etc.). Code 7 means surgery is exactly what      was recommended by the physician and the patient refused. If two treatment alternatives were offered and surgery was not chosen, code Reason no surgery of primary site as 1 [Surgery of the primary site was not performed because it was not part of the planned first-course treatment]. 

d. Assign code 8 when surgery is recommended, but it is unknown if the patient actually had the surgery 

Example: There is documentation in the medical record that the primary care physician referred the patient to a surgical oncologist. Follow-back to the surgical oncologist and primary care physician yields no further information. Assign code 8, it is known that surgery was recommended but there is no information on whether or not the patient actually had the surgical procedure.
Note: Review cases coded 8 periodically for later confirmation of surgery.

3. Assign code 9
      a. When there is no documentation that surgery was recommended or performed
      b. For death certificate only (DCO) cases
      c. Autopsy only cases