Anatomical site
Histologic behavior:

• Malignant Primary
• Malignant Secondary
• In situ
• Benign
• Uncertain
• Unspecified behavior

Skin neoplasms:

• Basal cell carcinoma
• Squamous cell carcinoma
• Specified type NEC

General Documentation:

• Anatomical Site
•  Laterality (left, right)
• Histologic behavior:
  – Benign
  – Malignant, primary and secondary sites if metastatic
  – In situ
  – Uncertain
  – Unspecified behavior
• Histologic Type:
  – Carcinoma
  – Basal Cell
  – Squamous Cell
  – Adenoma
• Complications or Adverse effects of antineoplastic or immunosuppressive drugs
• Previous excision or eradication

Breast, in-situ, document:

• Lobular
• Intraductal

Leukemia, Multiple Myeloma, Malignant plasma cell neoplasms, document:

• Relapse
• Remission
• Not having achieved remission

Pathologists may need to work with their referring physician to obtain this information.
When patients have more than one malignant tumor in the same organ document the primary and metastatic disease.

•  Chronic
•  Stage

Chronic Kidney Disease, document:

•  Stage 1
• Stage 2 (mild)
•  Stage 3 (moderate)
• Stage 4 (severe)
•  Stage 5
•  Co-morbidities (e.g. DM, HTN)
•  Specify any associated kidney failure

Urinary Incontinence, document:

•  Stress
•  Urge
•  Without sensory awareness
•  Post-void dribbling
•  Nocturnal enuresis
•  Continuous leakage
•  Mixed
•  Overflow

Hematuria, document:

•  Recurrent
•  Persistent
•  Any applicable underlying condition(s)

Neurogenic bladder, document:

•  Uninhibited
•  Reflex
•  Flaccid
•  Any associated urinary incontinence

Prolapse, document:

• Site
•  Complete (3rd degree) or incomplete (1st/2nd degree)

Codes from Chapter 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly.

• Unilateral, Bilateral
•  Type

General Documentation:

• Laterality (right, left, unilateral, bilateral)
•  Specify distinction between existing malformation or deformity vs. personal history.

Cleft palate, document:

•  Hard
•  Soft
• Hard w/soft

Cleft lip, document:

• Bilateral
•  Median
•  Unilateral

Hypospadias, document:

•  Site of the urethral opening:
  – Balanic
  – Penile
  – Penoscrotal
  – Perineal
  – Congenital chordae
  – Other specified

Malformation, deformation or chromosomal abnormality may be the principal / first-listed diagnosis or a secondary diagnosis.
Although present at birth malformation, deformation or chromosomal abnormality may not be identified until later in life.
Conditions listed in Chapter 17 may be used throughout the life of the patient